=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235697426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVISIONAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2019
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3819 PHELAN BLVD
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77707-2243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-363-5022
-----------------------------------------------------
Fax | 409-363-5015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2280 SUNFLOWER ST
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77713-9214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-404-9870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLINE PIERRE-LOUIS CENATUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-404-9870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------