Provider Demographics
NPI:1922005735
Name:EXCELLACARE SKILLED SERVICES INC.
Entity Type:Organization
Organization Name:EXCELLACARE SKILLED SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GWIZDZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN MBA
Authorized Official - Phone:248-476-9091
Mailing Address - Street 1:20853 FARMINGTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5183
Mailing Address - Country:US
Mailing Address - Phone:248-476-9091
Mailing Address - Fax:
Practice Address - Street 1:20853 FARMINGTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5183
Practice Address - Country:US
Practice Address - Phone:248-476-9091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFACILITY # 638801251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15 4087806Medicaid
MI15 4087806Medicaid