Basic Information
| Provider Information | |||||||||
| NPI: | 1710143375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAINEER HOMECARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MOUNTAINEER HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3374434154 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 TRACY WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047200205 | ||||||||
| FaxNumber: | 3047200262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 3810013957 | 05 | WV | MEDICAID |