Provider Demographics
NPI:1073248845
Name:PROVISION HEALTH CARE LLC
Entity Type:Organization
Organization Name:PROVISION HEALTH CARE LLC
Other - Org Name:FAMILY CONVENIENCE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:318-322-9252
Mailing Address - Street 1:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-0510
Mailing Address - Country:US
Mailing Address - Phone:318-322-9252
Mailing Address - Fax:
Practice Address - Street 1:2933 CYPRESS ST STE 1
Practice Address - Street 2:HALL B
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5468
Practice Address - Country:US
Practice Address - Phone:318-322-3637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2607090Medicaid