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General NPI Number Information
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NPI Number | 1912718016
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Entity Type | Organization
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Legal Business Name | PROVIDENT HEALTH CARE INC
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Dates
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Enumeration Date | 01/17/2025
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Last Update Date | 01/17/2025
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Provider Practice Location Address
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Address Line | 1553 TAMARACK AVE
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City | ATWATER
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State | CA
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Zip | 95301-2743
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Country | US
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Telephone | 209-388-1002
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Fax | 209-388-1007
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Provider Business Mailing Address
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Address Line | 1238 CATALINA DR
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City | MERCED
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State | CA
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Zip | 95348-9515
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Country | US
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Telephone | 209-388-1002
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Fax | 209-388-1007
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Authorized Official
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Title or Position | CEO
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Name | JERRY TIU
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Credential |
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Telephone | 209-388-1002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State |
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