1952350456 NPI number — PRIMESTAR HOME HEALTH OF NWLA INC

Table of content: (NPI 1952350456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952350456 NPI number — PRIMESTAR HOME HEALTH OF NWLA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMESTAR HOME HEALTH OF NWLA 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:
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:
1952350456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1527 DOCTORS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-259-1410
Provider Business Mailing Address Fax Number:
318-532-6088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINDEN
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71055-3320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-259-1410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASTLEMAN
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CHIEF OPERATING OFFICER/PARTNER
Authorized Official Telephone Number:
318-259-1410

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  438 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251E00000X , with the licence number: 12232 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1403326 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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