Provider Demographics
NPI:1457910648
Name:MEDERI PRIVATE CARE, LLC
Entity Type:Organization
Organization Name:MEDERI PRIVATE CARE, LLC
Other - Org Name:MEDERI PRIVATE CARE
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:337-233-5764
Practice Address - Street 1:2815 NW 13TH ST STE 322
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-2879
Practice Address - Country:US
Practice Address - Phone:352-554-8023
Practice Address - Fax:352-554-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104943900Medicaid