Provider Demographics
NPI:1659365864
Name:HOSPICE ADVANTAGE, LLC
Entity Type:Organization
Organization Name:HOSPICE ADVANTAGE, LLC
Other - Org Name:HOSPICE ADVANTAGE, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-452-1851
Mailing Address - Street 1:1026 S TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4773
Mailing Address - Country:US
Mailing Address - Phone:920-452-1851
Mailing Address - Fax:920-452-1852
Practice Address - Street 1:1026 S TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4773
Practice Address - Country:US
Practice Address - Phone:920-452-1851
Practice Address - Fax:920-452-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2010251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43190200Medicaid
WI43190200Medicaid