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General NPI Number Information
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NPI Number | 1396330890
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Entity Type | Organization
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Legal Business Name | PROVIDER SOURCE HOME HEALTH CARE
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Dates
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Enumeration Date | 03/05/2021
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Last Update Date | 03/05/2021
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Provider Practice Location Address
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Address Line | 2211 PRETTY LAKE AVE UNIT 403
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City | NORFOLK
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State | VA
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Zip | 23518-1047
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Country | US
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Telephone | 757-324-2979
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Fax | 757-257-4575
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Provider Business Mailing Address
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Address Line | 2211 PRETTY LAKE AVE UNIT 403
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City | NORFOLK
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State | VA
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Zip | 23518-1047
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Country | US
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Telephone | 757-324-2979
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Fax | 757-257-4575
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KENA DICKENS
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Credential |
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Telephone | 757-324-2979
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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 |
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License Number State |
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