Provider Demographics
NPI:1528513983
Name:PROVIZIONS CARE LLC
Entity type:Organization
Organization Name:PROVIZIONS CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:U
Authorized Official - Last Name:PROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-963-7552
Mailing Address - Street 1:5835 EXECUTIVE CENTER DR STE 101F
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8901
Mailing Address - Country:US
Mailing Address - Phone:704-963-7552
Mailing Address - Fax:
Practice Address - Street 1:424 LAKEWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-3148
Practice Address - Country:US
Practice Address - Phone:704-963-7552
Practice Address - Fax:774-307-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child