Basic Information
| Provider Information | |||||||||
| NPI: | 1518102938 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST ALABAMA HOMECARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHEAST ALABAMA HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 GLOVER AVE | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363302018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343474800 | ||||||||
| FaxNumber: | 3343474827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2008 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GACHASSIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 114029 | 05 | AL | MEDICAID |