Provider Demographics
NPI:1508039330
Name:PROVISIONS PERSONAL CARE SERVICES LLC
Entity Type:Organization
Organization Name:PROVISIONS PERSONAL CARE SERVICES LLC
Other - Org Name:PROVISIONS PERSONAL CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:NELLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR OF ARTS
Authorized Official - Phone:225-272-4146
Mailing Address - Street 1:15254 OLD HAMMOND HWY
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1275
Mailing Address - Country:US
Mailing Address - Phone:225-272-4146
Mailing Address - Fax:225-272-4147
Practice Address - Street 1:15254 OLD HAMMOND HWY
Practice Address - Street 2:SUITE A-3
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-1275
Practice Address - Country:US
Practice Address - Phone:225-272-4146
Practice Address - Fax:225-272-4147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-13
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPC0007626Medicaid