Provider Demographics
NPI:1932427309
Name:EXTENDICARE HEALTH FACILITIES, INC.
Entity Type:Organization
Organization Name:EXTENDICARE HEALTH FACILITIES, INC.
Other - Org Name:MICHIANA HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8119
Mailing Address - Street 1:111 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2903
Mailing Address - Country:US
Mailing Address - Phone:414-908-8119
Mailing Address - Fax:414-908-7105
Practice Address - Street 1:1420 E DOUGLAS ROAD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1733
Practice Address - Country:US
Practice Address - Phone:502-216-6344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201002500Medicaid
IN201002500Medicaid