Healthcare Provider Details

I. General information

NPI: 1558508648
Provider Name (Legal Business Name): PROVIDENT HOME HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 SILVERTON AVE SUITE 114
SAN DIEGO CA
92126-6342
US

IV. Provider business mailing address

7950 SILVERTON AVE SUITE 114
SAN DIEGO CA
92126-6342
US

V. Phone/Fax

Practice location:
  • Phone: 858-530-0442
  • Fax: 858-530-0545
Mailing address:
  • Phone: 858-530-0442
  • Fax: 858-530-0545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number175530
License Number StateCA

VIII. Authorized Official

Name: MRS. LUZ M LATUS
Title or Position: ADMINISTRATOR/ DPCS
Credential:
Phone: 858-530-0442