1609926195 NPI number — LITSON CERTIFIED CARE, INC.

Table of content: SUSAN KEALEY M.D. (NPI 1962551978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609926195 NPI number — LITSON CERTIFIED CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITSON CERTIFIED CARE, 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:
WILLCARE
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:
1609926195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2020
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:
700 CORPORATE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12550-6416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-561-3655
Provider Business Practice Location Address Fax Number:
845-331-0492
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GACHASSIN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY/TREASURER
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  3502601 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251J00000X , with the licence number: 3502601 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: 3502601 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02062944 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3947 . This is a "PFI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01599279 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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