=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912249624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDE HOMECARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2013
-----------------------------------------------------
Last Update Date | 03/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5419 E ESTATE RIDGE RD
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92807-4662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-283-2085
-----------------------------------------------------
Fax | 714-283-2085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5753G E SANTA ANA CANYON RD # 245
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92807-3229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-283-2085
-----------------------------------------------------
Fax | 714-283-2230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. VINCENT M. MIVEHCHI
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 714-283-2085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | C3320910
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | C3320910
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------