Provider Demographics
NPI:1952546988
Name:INNOVATIVE SENIOR CARE HOME HEALTH OF ST LOUIS LLC
Entity Type:Organization
Organization Name:INNOVATIVE SENIOR CARE HOME HEALTH OF ST LOUIS LLC
Other - Org Name:BROOKDALE HOME HEALTH ST. LOUIS
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 1:425 N NEW BALLAS RD
Practice Address - Street 2:STE 295
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6814
Practice Address - Country:US
Practice Address - Phone:314-993-7035
Practice Address - Fax:314-993-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO267603Medicare Oscar/Certification