Basic Information
| Provider Information | |||||||||
| NPI: | 1114951993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFELINE HOME HEALTH CARE OF SOMERSET, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LIFELINE HEALTH CARE OF PULASKI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 1 2 CLIFTY STREET | ||||||||
| Address2: | SUITE 2 AND 3 | ||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425031733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066799245 | ||||||||
| FaxNumber: | 6066789273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GACHASSIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | N | Agencies | Nursing Care | 253Z00000X | K150095 | KY | N | Agencies | In Home Supportive Care | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 3747P1801X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000000503507 | 01 | KY | ANTHEM BLUECROSS BLUESHIE | OTHER | 7100005740 | 05 | KY | MEDICAID | 7100003480 | 05 | KY | MEDICAID | 7100003460 | 05 | KY | MEDICAID | 7100003470 | 05 | KY | MEDICAID |