1790734036 NPI number — CORAM ALTERNATE SITE SERVICES INC

Table of content: (NPI 1790734036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790734036 NPI number — CORAM ALTERNATE SITE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORAM ALTERNATE SITE SERVICES INC
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:
CORAM CVS/SPECIALTY INFUSION SERVICES
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:
1790734036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 809160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60680-9160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-765-5043
Provider Business Mailing Address Fax Number:
401-733-0211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12310 WORLD TRADE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92128-3793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-576-6969
Provider Business Practice Location Address Fax Number:
858-974-6606
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LACAVICH
Authorized Official First Name:
TRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-306-3255

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  0800429 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251F00000X , with the licence number: 0800429 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHY50273 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0522311 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHA409320 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101225 . This is a "MEDICAL DEVICE RETAILER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0800429 . This is a "HOME HEALTH AGENCY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PHY50273 . This is a "PHARMACY LICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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