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General NPI Number Information
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NPI Number | 1740599240
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Entity Type | Organization
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Legal Business Name | PROVIDIAN TOTAL HEALTH LLC
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Dates
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Enumeration Date | 09/30/2010
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Last Update Date | 09/30/2010
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Provider Practice Location Address
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Address Line | 618 TRAVIS ST
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City | BAYTOWN
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State | TX
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Zip | 77520-7568
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Country | US
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Telephone | 832-512-3234
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Fax | 832-615-0813
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Provider Business Mailing Address
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Address Line | 718 MISTYCREEK DR
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City | RICHMOND
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State | TX
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Zip | 77406-1263
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Country | US
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Telephone |
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Fax | 832-615-0813
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Authorized Official
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Title or Position | MANAGER
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Name | MICHAEL IHEKORONYE
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Credential | RRT
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Telephone | 832-512-3234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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