Provider Demographics
NPI:1124150511
Name:PROVISION HOME CARE INC.
Entity type:Organization
Organization Name:PROVISION HOME CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MILLARD
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-569-4121
Mailing Address - Street 1:9378 OLIVE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3215
Mailing Address - Country:US
Mailing Address - Phone:314-569-4121
Mailing Address - Fax:
Practice Address - Street 1:9378 OLIVE BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3215
Practice Address - Country:US
Practice Address - Phone:314-569-4121
Practice Address - Fax:314-569-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCC0635954251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health