Provider Demographics
NPI:1114951993
Name:LIFELINE HOME HEALTH CARE OF SOMERSET, LLC
Entity Type:Organization
Organization Name:LIFELINE HOME HEALTH CARE OF SOMERSET, LLC
Other - Org Name:LIFELINE HEALTH CARE OF PULASKI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GACHASSIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:600 1 2 CLIFTY STREET
Practice Address - Street 2:SUITE 2 AND 3
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1733
Practice Address - Country:US
Practice Address - Phone:606-679-9245
Practice Address - Fax:606-678-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251J00000X, 261QR0400X, 261QR1300X, 3747P1801X
KYK150095253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000503507OtherANTHEM BLUECROSS BLUESHIE
KY7100005740Medicaid
KY7100003480Medicaid
KY7100003460Medicaid
KY7100003470Medicaid
KY187099Medicare Oscar/Certification