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General NPI Number Information
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NPI Number | 1225574734
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Entity Type | Organization
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Legal Business Name | PROVIDIAN HEALTHCARE LLC
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Dates
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Enumeration Date | 01/09/2017
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Last Update Date | 01/09/2017
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Provider Practice Location Address
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Address Line | 12409 WILLOW FOREST DR
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City | MOORPARK
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State | CA
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Zip | 93021-2763
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Country | US
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Telephone | 678-491-7870
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Fax |
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Provider Business Mailing Address
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Address Line | 12409 WILLOW FOREST DR
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City | MOORPARK
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State | CA
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Zip | 93021-2763
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Country | US
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Telephone | 678-491-7870
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. ELAINA HALL
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Credential |
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Telephone | 678-491-7870
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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