Provider Demographics
NPI:1568139160
Name:PERISSEUO GROUP LLC
Entity Type:Organization
Organization Name:PERISSEUO GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:JEANNETTE
Authorized Official - Last Name:HARDESTY
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT
Authorized Official - Phone:281-943-9997
Mailing Address - Street 1:135 OYSTER CREEK DR STE P
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4118
Mailing Address - Country:US
Mailing Address - Phone:979-480-1093
Mailing Address - Fax:979-429-4020
Practice Address - Street 1:135 OYSTER CREEK DR STE P
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4118
Practice Address - Country:US
Practice Address - Phone:979-480-1093
Practice Address - Fax:979-429-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4101131-01Medicaid