MEDICARE: PONCA CITY HOME CARE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000377089002	OTHER	OK	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1871530550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONCA CITY HOME CARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 51266
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70505-1266
Country	:	US
Telephone Number	:	337-233-1307
Fax Number	:	337-443-4154

Provider Business Practice Location Address
First Line	:	1924 LAKE RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-4800
Country	:	US
Telephone Number	:	580-765-8155
Fax Number	:	580-763-4549

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOSHUA L. PROFFITT
Credential	:
Telephone Number	:	337-233-1307

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	05/25/2023

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