1295181972 NPI number — CARESOURCE AT HOME, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295181972 NPI number — CARESOURCE AT HOME, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARESOURCE AT HOME, 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:
Provider Other Organization Name Type Code:
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:
1295181972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3455 MILL RUN DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
HILLIARD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43026-9078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-385-8620
Provider Business Mailing Address Fax Number:
614-385-8621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3455 MILL RUN DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HILLIARD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43026-9078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-385-8620
Provider Business Practice Location Address Fax Number:
614-385-8621
Provider Enumeration Date:
05/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LAGANA
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF INTEGRATED CARE
Authorized Official Telephone Number:
614-385-8260

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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