Provider Demographics
NPI:1073506457
Name:PROVIDENCE HEALTH SERVICES OF WACO
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES OF WACO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:KEAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-751-4000
Mailing Address - Street 1:PO BOX 201157
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1157
Mailing Address - Country:US
Mailing Address - Phone:254-741-2495
Mailing Address - Fax:254-741-2496
Practice Address - Street 1:540 MEADOWLAKE CTR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3981
Practice Address - Country:US
Practice Address - Phone:254-741-2495
Practice Address - Fax:254-741-2496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000111335E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX087277201Medicaid
515091OtherBLUE CROSS BLUE SHIELD
TX016043401Medicaid
TX087277201Medicaid