Basic Information
Provider Information | |||||||||
NPI: | 1083670418 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REVERENCE HOME HEALTH & HOSPICE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASCENSION AT HOME | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 CADILLAC DR STE 400 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370271001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153777022 | ||||||||
FaxNumber: | 6153734457 | ||||||||
Practice Location | |||||||||
Address1: | 5220 LOVERS LN STE 130 | ||||||||
Address2: |   | ||||||||
City: | PORTAGE | ||||||||
State: | MI | ||||||||
PostalCode: | 490021528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882466322 | ||||||||
FaxNumber: | 8107624110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 02/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ADKINS | ||||||||
AuthorizedOfficialFirstName: | RUSSELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SVP CHIEF LEGAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6153095668 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | N |   | Agencies | Home Health |   | 251E00000X |   | MI | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 10208 | 01 | MI | HEALTH PLAN OF MICHIGAN | OTHER | 381329216000 | 01 | MI | COMMUNITY CHOICE OF MI | OTHER | 6039047 | 01 | MI | PHP HOME HEALTH | OTHER | OE021 | 01 | MI | BLUE CROSS HOME HEALTH | OTHER |