Healthcare Provider Details

I. General information

NPI: 1689330417
Provider Name (Legal Business Name): PROV16, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 10/01/2022
Certification Date: 10/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST STE 206
BOISE ID
83705-1922
US

IV. Provider business mailing address

1111 S ORCHARD ST STE 206
BOISE ID
83705-1922
US

V. Phone/Fax

Practice location:
  • Phone: 208-285-2353
  • Fax:
Mailing address:
  • Phone: 208-285-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH HERRERA
Title or Position: DIRECTOR OF CONTRACT PROCUREMENT
Credential:
Phone: 714-588-7873