=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154580686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NINE PALMS 1 LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 07/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11815 ASPENGRAF LANE SUITE B
-----------------------------------------------------
City | NEW KENT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23124-2129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-966-5996
-----------------------------------------------------
Fax | 804-966-7260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5959 S SHERWOOD FOREST BLVD
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70816-6038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-292-2031
-----------------------------------------------------
Fax | 225-295-9678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | WILLIAM BORNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-292-2031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------