MEDICARE: PROVIDENCE EXCEL HOME CARE

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	CSS0016	OK

General Provider Information

NPI Number	:	1982905436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE EXCEL HOME CARE

Provider Business Mailing Address
First Line	:	4845 S SHERIDAN RD STE 502
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-5719
Country	:	US
Telephone Number	:	918-794-4334
Fax Number	:	918-794-4344

Provider Business Practice Location Address
First Line	:	4845 S SHERIDAN RD STE 502
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-5719
Country	:	US
Telephone Number	:	918-794-4334
Fax Number	:	918-794-4344

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. AMOS O. ADESOKAN
Credential	:	RN BSN
Telephone Number	:	918-625-4797

Provider Enumeration Date	:	11/15/2010
Last Update Date	:	11/15/2010

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