1063467801 NPI number — TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, LLC

Table of content: (NPI 1063467801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063467801 NPI number — TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, 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:
6
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:
1063467801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3854 AMERICAN WAY STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-4897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-299-3253
Provider Business Mailing Address Fax Number:
225-295-9678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6353 CENTER DR
Provider Second Line Business Practice Location Address:
BUILDING 8, SUITE 205
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-4112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-466-1340
Provider Business Practice Location Address Fax Number:
757-466-1668
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIGLICCO
Authorized Official First Name:
TRAVIS
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP TAX
Authorized Official Telephone Number:
225-299-3803

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: 010216982 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201031840009 . This is a "TRICARE HEALTH CARE PPS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 497498 . This is a "HUMANA GOLD CHOICE PPS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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