Basic Information
| Provider Information | |||||||||
| NPI: | 1013961267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENDER LOVING CARE HEALTH CARE SERVICES WESTERN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMEDISYS HOME HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3854 AMERICAN WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252922031 | ||||||||
| FaxNumber: | 2252959678 | ||||||||
| Practice Location | |||||||||
| Address1: | 5045 N 12TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850143374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022000835 | ||||||||
| FaxNumber: | 6022008465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | KUSSEROW | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252922031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HHA3720 | AZ | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 958879 | 01 | AZ | ARIZONA PHYSICIAN IPA | OTHER | 958879 | 05 | AZ | MEDICAID | 037106 | 01 | AZ | SECURE HORIZONS DIRECT PP | OTHER | 037106 | 01 | AZ | GROUP HEALTH COOPERATIVE | OTHER | 037106 | 01 | AZ | HUMANA PPS | OTHER |