Provider Demographics
NPI:1184848970
Name:BOONE MEMORIAL HOMECARE, LLC
Entity Type:Organization
Organization Name:BOONE MEMORIAL HOMECARE, LLC
Other - Org Name:BOONE MEMORIAL HOMECARE
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:337-443-4154
Practice Address - Street 1:298 TRICORN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25053-7148
Practice Address - Country:US
Practice Address - Phone:304-369-1385
Practice Address - Fax:304-369-9684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010764Medicaid
WV3810010764Medicaid