Basic Information
Provider Information | |||||||||
NPI: | 1053579102 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRANT MEMORIAL HOMECARE AND HOSPICE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GRANT MEMORIAL HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 51266 | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705051266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372331307 | ||||||||
FaxNumber: | 3372335764 | ||||||||
Practice Location | |||||||||
Address1: | 100 HOSPITAL DRIVE | ||||||||
Address2: | SUITE 2 | ||||||||
City: | PETERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 268479409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042572005 | ||||||||
FaxNumber: | 3042572093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2008 | ||||||||
LastUpdateDate: | 07/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GACHASSIN | ||||||||
AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3372331307 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X |   |   | N |   | Nursing & Custodial Care Facilities | Hospice, Inpatient |   | 251G00000X | 16 | WV | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 3810013853 | 05 | WV |   | MEDICAID | 3810013879 | 01 | WV | MEDICAID - NURSING HOME | OTHER |