Provider Demographics
NPI:1396330890
Name:PROVIDER SOURCE HOME HEALTH CARE
Entity type:Organization
Organization Name:PROVIDER SOURCE HOME HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-324-2979
Mailing Address - Street 1:2211 PRETTY LAKE AVE UNIT 403
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-1047
Mailing Address - Country:US
Mailing Address - Phone:757-324-2979
Mailing Address - Fax:757-257-4575
Practice Address - Street 1:2211 PRETTY LAKE AVE UNIT 403
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-1047
Practice Address - Country:US
Practice Address - Phone:757-324-2979
Practice Address - Fax:757-257-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health