Provider Demographics
NPI:1104416247
Name:PROVIDENTIAL HOME CARE OF NWA LLC
Entity type:Organization
Organization Name:PROVIDENTIAL HOME CARE OF NWA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-668-4338
Mailing Address - Street 1:113 PARKWOOD ST STE B
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-8811
Mailing Address - Country:US
Mailing Address - Phone:479-668-4338
Mailing Address - Fax:888-247-6285
Practice Address - Street 1:113 PARKWOOD ST STE B
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8811
Practice Address - Country:US
Practice Address - Phone:479-668-4338
Practice Address - Fax:888-247-6285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR234403732Medicaid