Healthcare Provider Details

I. General information

NPI: 1457745960
Provider Name (Legal Business Name): PROVISIONS HEALTHCARE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

E2535 CEDAR RD
ELEVA WI
54738-9083
US

IV. Provider business mailing address

E2535 CEDAR RD
ELEVA WI
54738-9083
US

V. Phone/Fax

Practice location:
  • Phone: 715-450-3391
  • Fax:
Mailing address:
  • Phone: 715-450-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL

VIII. Authorized Official

Name: KATIE ANIBAS
Title or Position: PRESIDENT
Credential:
Phone: 715-450-3391