1518912377 NPI number — NINE PALMS 1, LLC

Table of content: (NPI 1518912377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518912377 NPI number — NINE PALMS 1, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NINE PALMS 1, 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:
BROOKSIDE HOME HEALTH, 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:
1518912377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2016
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:
460 MCLAWS CIR
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23185-5671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-253-2536
Provider Business Practice Location Address Fax Number:
757-253-8086
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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004971159 . This is a "VA PRIEIMER HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 442171 . This is a "BCBS VA ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 004971248 . This is a "VA PRIEIMER HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 226349 . This is a "MAMSI HEALTH PLANS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 442173 . This is a "BCBS VA ANTHEM" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 442175 . This is a "BCBS VA ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 442235 . This is a "BCBS VA ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5965078 . This is a "AETNA US HEALTH CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010194881 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 299072 . This is a "MAMSI HEALTH PLANS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4971159 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1851340 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4971248 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4971264 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19649 . This is a "SENTARA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 236402 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4971256 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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