Provider Demographics
NPI:1447429618
Name:PROVISION HOME HEALTHCARE, INC
Entity Type:Organization
Organization Name:PROVISION HOME HEALTHCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGENA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-335-3689
Mailing Address - Street 1:17065 DIXIE HWY STE 36
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1384
Mailing Address - Country:US
Mailing Address - Phone:708-335-3689
Mailing Address - Fax:
Practice Address - Street 1:17065 DIXIE HWY STE 36
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1384
Practice Address - Country:US
Practice Address - Phone:708-335-3689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health