Healthcare Provider Details

I. General information

NPI: 1962407247
Provider Name (Legal Business Name): PROVIDENCE CARE HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1269 N MAIN ST
VIDOR TX
77662-3740
US

IV. Provider business mailing address

1269 N MAIN ST
VIDOR TX
77662-3740
US

V. Phone/Fax

Practice location:
  • Phone: 409-813-2273
  • Fax: 409-813-2272
Mailing address:
  • Phone: 409-813-2273
  • Fax: 409-813-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number009147
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number14926
License Number StateTX

VIII. Authorized Official

Name: ELIZABETH ANN WATTS
Title or Position: ADMINISTRATOR
Credential: DO
Phone: 409-813-2273