Basic Information
| Provider Information | |||||||||
| NPI: | 1104871094 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NINE PALMS 2 LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TENDER LOVING CARE, AN AMEDISYS COMPANY | ||||||||
| 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: | 11010 HIGHWAY 49 | ||||||||
| Address2: | STE 4 | ||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395034190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288319821 | ||||||||
| FaxNumber: | 2288319826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | KUSSEROW | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252922031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 12384 | MS | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000070508 | 01 | MS | BC BS OF MS FED | OTHER | 000070507 | 01 | MS | BC BS OF MS | OTHER | 00770616 | 05 | MS | MEDICAID | 000070508 | 01 | MS | BC BS OF MS | OTHER | 000070507 | 01 | MS | ADVANCED HEALTH SYSTEMS | OTHER | 000070508 | 01 | MS | ADVANCED HEALTH SYSTEMS | OTHER |