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General NPI Number Information
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NPI Number | 1770855231
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Entity Type | Organization
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Legal Business Name | PROVISION HOME HEALTH
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Dates
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Enumeration Date | 01/30/2012
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Last Update Date | 01/30/2012
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Provider Practice Location Address
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Address Line | 3823 E LOOP 820 S
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City | FORT WORTH
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State | TX
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Zip | 76119-4337
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Country | US
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Telephone | 817-449-7193
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Fax |
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Provider Business Mailing Address
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Address Line | 3823 E LOOP 820 S
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City | FORT WORTH
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State | TX
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Zip | 76119-4337
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Country | US
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Telephone | 817-449-7193
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Fax |
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Authorized Official
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Title or Position | ALTERNATE ADMINISTRATOR
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Name | MS. TANISHA PERELLE MANUEL
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Credential | LVN
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Telephone | 817-449-7193
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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 | 173042
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License Number State | TX
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