Provider Demographics
NPI:1386647659
Name:PRIMESTAR HOME HEALTH
Entity Type:Organization
Organization Name:PRIMESTAR HOME HEALTH
Other - Org Name:HAWORTH HOME HEALTH, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASTLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, HCS-C
Authorized Official - Phone:318-259-1410
Mailing Address - Street 1:235 DESIARD ST.
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-329-8292
Mailing Address - Fax:318-490-4364
Practice Address - Street 1:1008 JULIA ST
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269
Practice Address - Country:US
Practice Address - Phone:318-329-8292
Practice Address - Fax:318-490-4364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1401609Medicaid
LA1401609Medicaid