MEDICARE: PROVIDENCE HEALTH CARE AND ASSISTED LIVING

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	343800000X	Secured Medical Transport (VAN)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1144811589	OTHER	TX	NPI

General Provider Information

NPI Number	:	1083354773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH CARE AND ASSISTED LIVING

Provider Business Mailing Address
First Line	:	2906 FORT STOCKTON DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-6257
Country	:	US
Telephone Number	:	210-322-9647
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 FORT STOCKTON DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-6257
Country	:	US
Telephone Number	:	210-322-9647
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	RAYCHELLE SANDERS
Credential	:
Telephone Number	:	210-322-9647

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	03/30/2022

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