Healthcare Provider Details

I. General information

NPI: 1073251880
Provider Name (Legal Business Name): INNOVATIVE SENIOR CARE HOME HEALTH OF CHARLOTTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 OLD PROVIDENCE RD
CHARLOTTE NC
28226-6872
US

IV. Provider business mailing address

PO BOX 51266
LAFAYETTE LA
70505-1266
US

V. Phone/Fax

Practice location:
  • Phone: 704-365-8551
  • Fax: 704-921-2055
Mailing address:
  • Phone: 337-233-1307
  • Fax: 337-443-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS GACHASSIN III
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 337-233-1307