Provider Demographics
NPI:1598157604
Name:PROVIDENT HEALTH CARE INC.
Entity Type:Organization
Organization Name:PROVIDENT HEALTH CARE INC.
Other - Org Name:PROVIDENT HEALTH CARE WINDY GAP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
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 1:42406 WINDY GAP DR
Practice Address - Street 2:
Practice Address - City:AHWAHNEE
Practice Address - State:CA
Practice Address - Zip Code:93601
Practice Address - Country:US
Practice Address - Phone:559-683-8020
Practice Address - Fax:209-722-7087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3480108315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities