Provider Demographics
NPI:1518912377
Name:NINE PALMS 1, LLC
Entity Type:Organization
Organization Name:NINE PALMS 1, LLC
Other - Org Name:BROOKSIDE HOME HEALTH, AN AMEDISYS COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSSEROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-292-2031
Mailing Address - Street 1:3854 AMERICAN WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4013
Mailing Address - Country:US
Mailing Address - Phone:225-292-2031
Mailing Address - Fax:225-295-9678
Practice Address - Street 1:460 MCLAWS CIR
Practice Address - Street 2:STE 250
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5671
Practice Address - Country:US
Practice Address - Phone:757-253-2536
Practice Address - Fax:757-253-8086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004971159OtherVA PRIEIMER HEALTH PLAN
VA442171OtherBCBS VA ANTHEM
VA004971248OtherVA PRIEIMER HEALTH PLAN
VA226349OtherMAMSI HEALTH PLANS
VI442173OtherBCBS VA ANTHEM
VA442175OtherBCBS VA ANTHEM
VA442235OtherBCBS VA ANTHEM
VA5965078OtherAETNA US HEALTH CARE
VA010194881Medicaid
VA299072OtherMAMSI HEALTH PLANS
VA4971159Medicaid
VA1851340OtherCIGNA
VA4971248Medicaid
VA4971264Medicaid
VA19649OtherSENTARA HEALTH PLAN
VA236402OtherMAMSI
VA4971256Medicaid
VA442235OtherBCBS VA ANTHEM
VA4971256Medicaid
VA236402OtherMAMSI