Basic Information
Provider Information | |||||||||
NPI: | 1740250612 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLEVELAND HOME CARE SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TENNOVA HOME HEALTH - CLEVELAND | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 51266 | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705051266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372231307 | ||||||||
FaxNumber: | 3374434154 | ||||||||
Practice Location | |||||||||
Address1: | 2440 OAKLAND DR NW | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | TN | ||||||||
PostalCode: | 373111346 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4235596092 | ||||||||
FaxNumber: | 4235596093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 09/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PROFFITT | ||||||||
AuthorizedOfficialFirstName: | JOSHUA | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 3372331307 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 0000000013 | TN | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 4114888 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 4114888 | 01 | TN | BLUE CARE/TENNCARE SELECT | OTHER | 702010661 | 01 | TN | CARITEN MEDICARE HMO | OTHER | Q020080 | 05 | TN |   | MEDICAID |