Provider Demographics
NPI:1194980615
Name:INNOVATIVE SENIOR CARE HOME HEALTH OF PORTLAND LLC
Entity type:Organization
Organization Name:INNOVATIVE SENIOR CARE HOME HEALTH OF PORTLAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GACHASSIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-443-4154
Practice Address - Street 1:7750 SW MOHAWK STREET
Practice Address - Street 2:BLDG G, SUITE 7750
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9191
Practice Address - Country:US
Practice Address - Phone:503-582-9246
Practice Address - Fax:503-685-9047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR387127Medicare Oscar/Certification