Provider Demographics
NPI:1366988412
Name:PROVIDENCE MISSION MINISTRY LLC
Entity type:Organization
Organization Name:PROVIDENCE MISSION MINISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-774-8785
Mailing Address - Street 1:PO BOX 1293
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-1293
Mailing Address - Country:US
Mailing Address - Phone:281-774-8785
Mailing Address - Fax:832-543-5006
Practice Address - Street 1:21 ALPINE ST
Practice Address - Street 2:
Practice Address - City:COLDSPRING
Practice Address - State:TX
Practice Address - Zip Code:77331-8058
Practice Address - Country:US
Practice Address - Phone:936-647-2227
Practice Address - Fax:936-647-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX371798501Medicaid