MEDICARE: PROVIDENCE HOME

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	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1700105426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HOME

Provider Business Mailing Address
First Line	:	8108 MODESTO DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-8545
Country	:	US
Telephone Number	:	817-715-0236
Fax Number	:

Provider Business Practice Location Address
First Line	:	8108 MODESTO DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-8545
Country	:	US
Telephone Number	:	817-715-0236
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	SAAGHE MMBI FOGWE
Credential	:
Telephone Number	:	817-715-0236

Provider Enumeration Date	:	05/20/2010
Last Update Date	:	05/20/2010

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Directions to “PROVIDENCE HOME ” Practice Location

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