Provider Demographics
NPI:1104928332
Name:HOSPICE ADVANTAGE, LLC
Entity type:Organization
Organization Name:HOSPICE ADVANTAGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KAYANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYNSBERGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-891-2210
Mailing Address - Street 1:401 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-5939
Mailing Address - Country:US
Mailing Address - Phone:989-891-2206
Mailing Address - Fax:989-893-5268
Practice Address - Street 1:951 MAIN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1039
Practice Address - Country:US
Practice Address - Phone:262-864-4145
Practice Address - Fax:262-864-4209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2017251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43190800Medicaid
WI43190800Medicaid