=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235365792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDER HEALTH SERVICES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2009
-----------------------------------------------------
Last Update Date | 02/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6161 BUSCH BLVD # 168
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43229-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-352-7092
-----------------------------------------------------
Fax | 614-681-9098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6161 BUSCH BLVD STE 128
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43229-2586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-681-9099
-----------------------------------------------------
Fax | 614-681-9098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MISS JOSEPHINE TALIEH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-681-9099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1735736
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------