1104871094 NPI number — NINE PALMS 2 LLC

Table of content: (NPI 1104871094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104871094 NPI number — NINE PALMS 2 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NINE PALMS 2 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:
TENDER LOVING CARE, AN AMEDISYS COMPANY
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:
1104871094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3854 AMERICAN WAY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-292-2031
Provider Business Mailing Address Fax Number:
225-295-9678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11010 HIGHWAY 49
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503-4190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-831-9821
Provider Business Practice Location Address Fax Number:
228-831-9826
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUSSEROW
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
225-292-2031

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  12384 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000070508 . This is a "BC BS OF MS FED" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 000070507 . This is a "BC BS OF MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00770616 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000070508 . This is a "BC BS OF MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 000070507 . This is a "ADVANCED HEALTH SYSTEMS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 000070508 . This is a "ADVANCED HEALTH SYSTEMS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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