MEDICARE: PROVISION SOLUTIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063652741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVISION SOLUTIONS, LLC

Provider Business Mailing Address
First Line	:	5320 TOMAHAWK TRL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-6017
Country	:	US
Telephone Number	:	919-623-5903
Fax Number	:

Provider Business Practice Location Address
First Line	:	5320 TOMAHAWK TRL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-6017
Country	:	US
Telephone Number	:	919-623-5903
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. SAMUEL MOSS
Credential	:
Telephone Number	:	919-623-5907

Provider Enumeration Date	:	02/20/2009
Last Update Date	:	02/20/2009

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