Basic Information
| Provider Information | |||||||||
| NPI: | 1780279075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRGINIA IN-HOME PARTNER-XII, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WYTHE PALLIATIVE CARE OF SOUTHWEST VIRGINIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331370 | ||||||||
| FaxNumber: | 3374434154 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WYTHEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243821096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762280840 | ||||||||
| FaxNumber: | 2762269167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GACHASSIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.