Provider Demographics
NPI:1881846087
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:CEO
Authorized Official - Prefix:MR
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 1:6606 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061
Practice Address - Country:US
Practice Address - Phone:804-758-1311
Practice Address - Fax:804-758-8817
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NINE PALMS 1, LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-21
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1881846087Medicaid
VA1881846087Medicaid