Provider Demographics
NPI:1700259264
Name:PROVISION HOME CARE INC
Entity type:Organization
Organization Name:PROVISION HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:OPOKU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:314-569-4121
Mailing Address - Street 1:9378 OLIVE BLVD
Mailing Address - Street 2:SUITE #215
Mailing Address - City:OLIVETTE
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:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3215
Practice Address - Country:US
Practice Address - Phone:314-569-4121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSSBG/GR0008084251F00000X, 251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251F00000XAgenciesHome Infusion
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOSSBG/GR0008084Medicaid