Basic Information
| Provider Information | |||||||||
| NPI: | 1396799474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENDER LOVING CARE HEALTH CARE SERVICES OF WEST VIRGINIA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMEDISYS HOSPICE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3854 AMERICAN WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252922031 | ||||||||
| FaxNumber: | 2252959678 | ||||||||
| Practice Location | |||||||||
| Address1: | 5006 MID ATLANTIC DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265084290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042924868 | ||||||||
| FaxNumber: | 3042924867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2006 | ||||||||
| LastUpdateDate: | 09/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | KUSSEROW | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2252922031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | 19 | WV | N | Nursing & Custodial Care Facilities | Hospice, Inpatient | 251G00000X | 19 | WV | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 3810003295 | 05 | WV | MEDICAID | 2594938 | 05 | OH | MEDICAID | 3810019181 | 05 | WV | MEDICAID | 1703595 | 01 | WV | WV BCBS HOSPICE | OTHER | 3810003007 | 05 | WV | MEDICAID | 3810003296 | 05 | WV | MEDICAID |