Basic Information
Provider Information | |||||||||
NPI: | 1245872225 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNCREST HOME HEALTH OF TAMPA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUNCREST OMNI | ||||||||
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: |   | ||||||||
Practice Location | |||||||||
Address1: | 311 PARK PLACE BLVD STE 120 | ||||||||
Address2: |   | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337594904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7272606680 | ||||||||
FaxNumber: | 7274418311 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2019 | ||||||||
LastUpdateDate: | 04/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GACHASSIN | ||||||||
AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3372331307 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | N |   | Agencies | Home Health |   | 253Z00000X |   |   | Y |   | Agencies | In Home Supportive Care |   |
ID Information
ID | Type | State | Issuer | Description | 104652000 | 05 | FL |   | MEDICAID |