Healthcare Provider Details

I. General information

NPI: 1386623700
Provider Name (Legal Business Name): PETERSBURG HOME CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 OLD WAGNER RD BLDG A
PETERSBURG VA
23805-9313
US

IV. Provider business mailing address

9510 ORMSBY STATION RD STE 300
LOUISVILLE KY
40223-4081
US

V. Phone/Fax

Practice location:
  • Phone: 804-862-8345
  • Fax: 804-862-3461
Mailing address:
  • Phone: 502-891-1187
  • Fax: 502-891-8067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number497072
License Number StateVA

VIII. Authorized Official

Name: MR. NICHOLAS GACHASSIN III
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 501-891-1044