Provider Demographics
NPI:1154706075
Name:PROVIDENT HEALTHCARE LLC
Entity type:Organization
Organization Name:PROVIDENT HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAKSHMAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:DINAVAHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-390-0120
Mailing Address - Street 1:3063 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8639
Mailing Address - Country:US
Mailing Address - Phone:678-390-0120
Mailing Address - Fax:
Practice Address - Street 1:3505 LASSITER FALLS DR NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-4199
Practice Address - Country:US
Practice Address - Phone:414-916-9031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07088207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty