Healthcare Provider Details

I. General information

NPI: 1881846087
Provider Name (Legal Business Name): NINE PALMS 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6606 MAIN ST
GLOUCESTER VA
23061
US

IV. Provider business mailing address

3854 AMERICAN WAY SUITE A
BATON ROUGE LA
70816-4013
US

V. Phone/Fax

Practice location:
  • Phone: 804-758-1311
  • Fax: 804-758-8817
Mailing address:
  • Phone: 225-292-2031
  • Fax: 225-295-9678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL KUSSEROW
Title or Position: CEO
Credential:
Phone: 225-292-2031