Provider Demographics
NPI:1215429386
Name:BLACKSTONE LIFE CARE, LLC
Entity type:Organization
Organization Name:BLACKSTONE LIFE CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE & PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-774-4263
Mailing Address - Street 1:900 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:VA
Mailing Address - Zip Code:23824-2644
Mailing Address - Country:US
Mailing Address - Phone:434-292-5301
Mailing Address - Fax:434-292-6041
Practice Address - Street 1:900 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSTONE
Practice Address - State:VA
Practice Address - Zip Code:23824-2644
Practice Address - Country:US
Practice Address - Phone:434-292-5301
Practice Address - Fax:434-292-6041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4953533Medicaid
200515603OtherFEDERAL BLACK LUNG
180505OtherANTHEM BCBS