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General NPI Number Information
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NPI Number | 1124150511
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Entity Type | Organization
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Legal Business Name | PROVISION HOME CARE INC.
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9378 OLIVE BLVD SUITE 215
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City | SAINT LOUIS
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State | MO
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Zip | 63132-3215
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Country | US
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Telephone | 314-569-4121
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Fax | 314-569-4118
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Provider Business Mailing Address
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Address Line | 9378 OLIVE BLVD SUITE 215
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City | SAINT LOUIS
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State | MO
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Zip | 63132-3215
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Country | US
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Telephone | 314-569-4121
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Fax |
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Authorized Official
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Title or Position | BILLER
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Name | MR. KENNETH MILLARD ROBERTS
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Credential |
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Telephone | 314-569-4121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | CC0635954
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License Number State | MO
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