MEDICARE: PROVIDENCE GROUP 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1811219942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE GROUP HOME

Provider Business Mailing Address
First Line	:	3327 CHAPELWOOD DR
Second Line	:
City	:	SUNNYVALE
State	:	TX
Zip	:	75182-4005
Country	:	US
Telephone Number	:	214-680-9144
Fax Number	:	972-226-7935

Provider Business Practice Location Address
First Line	:	1047 HILLBURN DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-4328
Country	:	US
Telephone Number	:	214-680-9144
Fax Number	:	972-226-7935

Authorized Official
Title or Position	:	OWNER
Name	:	MR. POLYCARP ANAYO OHAKWE
Credential	:
Telephone Number	:	214-680-9144

Provider Enumeration Date	:	02/16/2010
Last Update Date	:	02/16/2010

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Directions to “PROVIDENCE GROUP HOME ” Practice Location

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