MEDICARE: PROVISION HOME HEALTH

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	251E00000X	Home Health Agency	173042	TX

General Provider Information

NPI Number	:	1770855231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVISION HOME HEALTH

Provider Business Mailing Address
First Line	:	3823 E LOOP 820 S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4337
Country	:	US
Telephone Number	:	817-449-7193
Fax Number	:

Provider Business Practice Location Address
First Line	:	3823 E LOOP 820 S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4337
Country	:	US
Telephone Number	:	817-449-7193
Fax Number	:

Authorized Official
Title or Position	:	ALTERNATE ADMINISTRATOR
Name	:	MS. TANISHA PERELLE MANUEL
Credential	:	LVN
Telephone Number	:	817-449-7193

Provider Enumeration Date	:	01/30/2012
Last Update Date	:	01/30/2012

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Directions to “PROVISION HOME HEALTH ” Practice Location

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