Basic Information
| Provider Information | |||||||||
| NPI: | 1295980498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, L.L.C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TENDER LOVING CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252922031 | ||||||||
| FaxNumber: | 2252959678 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 BREEZEPORT WAY | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574838914 | ||||||||
| FaxNumber: | 7574843723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2008 | ||||||||
| LastUpdateDate: | 05/04/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BORNE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252922031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, L.L.C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1295980498 | 05 | VA | MEDICAID |