Basic Information
| Provider Information | |||||||||
| NPI: | 1316994817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACADIAN HOME HEALTH CARE SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFF DAVIS HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 ELTON RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | JENNINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705464138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3378241188 | ||||||||
| FaxNumber: | 3378247007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STELLY | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1002 | LA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1400394 | 05 | LA | MEDICAID | 190030694Z | 01 | LA | BLUE CROSS BLUE SHIELD OF | OTHER |