Provider Demographics
NPI:1174690143
Name:AZZA PROVIDER SERVICES INC
Entity Type:Organization
Organization Name:AZZA PROVIDER SERVICES INC
Other - Org Name:AZZA HOME HEALTHCARE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AGATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:OKOJIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-703-8652
Mailing Address - Street 1:6501 NICOLE WAY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-2988
Mailing Address - Country:US
Mailing Address - Phone:817-703-8652
Mailing Address - Fax:817-467-2533
Practice Address - Street 1:6501 NICOLE WAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-2988
Practice Address - Country:US
Practice Address - Phone:817-703-8652
Practice Address - Fax:817-467-2533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010848251E00000X
251J00000X, 3747P1801X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX743126Medicare Oscar/Certification