Basic Information
Provider Information | |||||||||
NPI: | 1275764375 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNCREST HOME HEALTH OF AL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUNCREST HOME HEALTH | ||||||||
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: | 3374434154 | ||||||||
Practice Location | |||||||||
Address1: | 222 7TH ST S | ||||||||
Address2: |   | ||||||||
City: | CLANTON | ||||||||
State: | AL | ||||||||
PostalCode: | 350453704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2052804663 | ||||||||
FaxNumber: | 2052803489 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2009 | ||||||||
LastUpdateDate: | 07/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GACHASSIN | ||||||||
AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
AuthorizedOfficialTelephone: | 3372331307 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 124091 | 05 | AL |   | MEDICAID |