Provider Demographics
NPI:1962407247
Name:PROVIDENCE CARE HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:PROVIDENCE CARE HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:409-813-2273
Mailing Address - Street 1:1269 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-3740
Mailing Address - Country:US
Mailing Address - Phone:409-813-2273
Mailing Address - Fax:409-813-2272
Practice Address - Street 1:1269 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-3740
Practice Address - Country:US
Practice Address - Phone:409-813-2273
Practice Address - Fax:409-813-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009147251E00000X
TX14926251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172498101Medicaid
TX172498101Medicaid