Provider Demographics
NPI:1447561741
Name:INNOVATIVE SENIOR CARE HOME HEALTH OF EDMOND LLC
Entity Type:Organization
Organization Name:INNOVATIVE SENIOR CARE HOME HEALTH OF EDMOND LLC
Other - Org Name:BROOKDALE HOME HEALTH OKC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
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 1:5600 N MAY AVE
Practice Address - Street 2:STE 147
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3973
Practice Address - Country:US
Practice Address - Phone:405-341-4361
Practice Address - Fax:405-341-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK377666Medicare Oscar/Certification