Provider Demographics
NPI:1063467801
Name:TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, LLC
Entity type:Organization
Organization Name:TENDER LOVING CARE HEALTH CARE SERVICES SOUTHEAST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP TAX
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGLICCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-299-3803
Mailing Address - Street 1:3854 AMERICAN WAY STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4897
Mailing Address - Country:US
Mailing Address - Phone:225-299-3253
Mailing Address - Fax:225-295-9678
Practice Address - Street 1:6353 CENTER DR
Practice Address - Street 2:BUILDING 8, SUITE 205
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4112
Practice Address - Country:US
Practice Address - Phone:757-466-1340
Practice Address - Fax:757-466-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010216982Medicaid
VA201031840009OtherTRICARE HEALTH CARE PPS
VA497498OtherHUMANA GOLD CHOICE PPS
VA201031840009OtherTRICARE HEALTH CARE PPS