Provider Demographics
NPI:1740481787
Name:ADVANTAGE II
Entity type:Organization
Organization Name:ADVANTAGE II
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-281-6728
Mailing Address - Street 1:4021 N ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304
Mailing Address - Country:US
Mailing Address - Phone:765-281-6728
Mailing Address - Fax:765-284-1239
Practice Address - Street 1:4021 N ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1774
Practice Address - Country:US
Practice Address - Phone:765-281-6728
Practice Address - Fax:765-284-1239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200506490OtherMEDICAID WAIVER