Provider Demographics
NPI:1366499881
Name:CORAM ALTERNATE SITE SERVICES, INC.
Entity Type:Organization
Organization Name:CORAM ALTERNATE SITE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACAVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-407-1785
Mailing Address - Street 1:1675 BROADWAY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-4675
Mailing Address - Country:US
Mailing Address - Phone:303-672-8631
Mailing Address - Fax:303-298-0047
Practice Address - Street 1:206 ROXALANA BUSINESS PARK
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-2727
Practice Address - Country:US
Practice Address - Phone:304-768-1241
Practice Address - Fax:304-768-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251F00000X, 333600000X, 3336H0001X
WVN/A261QI0500X
WVSP0552256332BP3500X, 333600000X, 3336C0003X, 3336H0001X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5403328700Medicaid
KY90009721Medicaid
WV8508001Medicaid
5010486OtherNCPDP
WVSP0552256OtherRX LICENSE
WVSP0552256OtherRX LICENSE
0976970023Medicare NSC
CO09327173Medicare ID - Type UnspecifiedPART B LOCAL