Healthcare Provider Details

I. General information

NPI: 1285625186
Provider Name (Legal Business Name): PROVINCIAL HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 NW 58TH ST STE. 900
OKLAHOMA CITY OK
73112-4707
US

IV. Provider business mailing address

3555 NW 58TH ST STE. 900
OKLAHOMA CITY OK
73112-4707
US

V. Phone/Fax

Practice location:
  • Phone: 405-917-0650
  • Fax: 405-917-0656
Mailing address:
  • Phone: 405-917-0650
  • Fax: 405-917-0656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number4158
License Number StateOK

VIII. Authorized Official

Name: MR. STEVEN L EDWARDS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 405-917-0650