Basic Information
| Provider Information | |||||||||
| NPI: | 1538139910 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND HOME CARE SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | FAMILY HOSPICE CLEVELAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 24TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373113826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235596092 | ||||||||
| FaxNumber: | 4235596093 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 24TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373113826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235596092 | ||||||||
| FaxNumber: | 4235596093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTH OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NATIONAL HEALTHCARE OF CLEVELAND, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 0000000358 | TN | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 044-1505 | 05 | TN | MEDICAID | 4114881 | 01 | TN | BLUE CARE TENNCARE | OTHER |