Healthcare Provider Details

I. General information

NPI: 1316718067
Provider Name (Legal Business Name): PROVIZIONS CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 10/15/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

597 LOVE ST
CONCORD NC
28027
US

IV. Provider business mailing address

5835 EXECUTIVE CENTER DR STE 101F
CHARLOTTE NC
28212-8901
US

V. Phone/Fax

Practice location:
  • Phone: 704-963-7552
  • Fax: 774-307-2797
Mailing address:
  • Phone: 704-963-7552
  • Fax: 774-307-2797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LATASHA U PROSS
Title or Position: CEO
Credential:
Phone: 704-963-7552