Provider Demographics
NPI:1275879801
Name:PROVIDENT HEALTH CARE INC
Entity Type:Organization
Organization Name:PROVIDENT HEALTH CARE INC
Other - Org Name:PROVIDENTHEALTHCARE-TAMARACK HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/LICENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:TIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-723-4888
Mailing Address - Street 1:1238 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-9515
Mailing Address - Country:US
Mailing Address - Phone:209-723-4888
Mailing Address - Fax:209-722-7087
Practice Address - Street 1:1553 TAMARACK AVE
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-2743
Practice Address - Country:US
Practice Address - Phone:209-357-2212
Practice Address - Fax:209-557-5689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities