Healthcare Provider Details

I. General information

NPI: 1932434610
Provider Name (Legal Business Name): PROVIDENT HOME HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 ANTHONY LN S
ST ANTHONY MN
55418-3233
US

IV. Provider business mailing address

2852 ANTHONY LN S
ST ANTHONY MN
55418-3233
US

V. Phone/Fax

Practice location:
  • Phone: 612-238-4688
  • Fax: 612-238-4689
Mailing address:
  • Phone: 612-238-4688
  • Fax: 612-238-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number346508
License Number StateMN

VIII. Authorized Official

Name: RAMONA ERICKSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 612-238-4688