Healthcare Provider Details

I. General information

NPI: 1770113813
Provider Name (Legal Business Name): PALLIATIVE CARE AT HEART, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 N BROADWAY ST STE A
POTEAU OK
74953-5554
US

IV. Provider business mailing address

PO BOX 51266
LAFAYETTE LA
70505-1266
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-7008
  • Fax: 918-647-7168
Mailing address:
  • Phone: 337-233-1307
  • Fax: 337-443-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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