=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558271270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENTIA DME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2026
-----------------------------------------------------
Last Update Date | 09/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5350 BELLAIRE BLVD UNIT 42
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77402-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-902-4436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5350 BELLAIRE BLVD UNIT 42
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77402-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-902-4436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JARED M RANDLEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-902-4436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------