Provider Demographics
NPI:1467885343
Name:PROVENCIO HOME VISITS MHT LLC
Entity Type:Organization
Organization Name:PROVENCIO HOME VISITS MHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:POSTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-860-2109
Mailing Address - Street 1:1515 HERITAGE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-3256
Mailing Address - Country:US
Mailing Address - Phone:855-860-2109
Mailing Address - Fax:855-814-8428
Practice Address - Street 1:7116 OVAL ROCK DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-7666
Practice Address - Country:US
Practice Address - Phone:855-860-2109
Practice Address - Fax:855-814-8428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1809207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty