1235423864 NPI number — INNOVATIVE SENIOR CARE HOME HEALTH OF CHARLOTTE LLC

Table of content: (NPI 1235423864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235423864 NPI number — INNOVATIVE SENIOR CARE HOME HEALTH OF CHARLOTTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE SENIOR CARE HOME HEALTH OF CHARLOTTE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUNCREST HOME HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235423864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:
337-443-4154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9115 HARRIS CORNERS PKWY STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28269-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-921-2051
Provider Business Practice Location Address Fax Number:
704-921-2055
Provider Enumeration Date:
05/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GACHASSIN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC0369 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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