Healthcare Provider Details

I. General information

NPI: 1073506457
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES OF WACO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MEADOWLAKE CTR
WACO TX
76712-3981
US

IV. Provider business mailing address

PO BOX 201157
DALLAS TX
75320-1157
US

V. Phone/Fax

Practice location:
  • Phone: 254-741-2495
  • Fax: 254-741-2496
Mailing address:
  • Phone: 254-741-2495
  • Fax: 254-741-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number000111
License Number StateTX

VIII. Authorized Official

Name: MR. KENT KEAHEY
Title or Position: CEO
Credential:
Phone: 254-751-4000