Provider Demographics
NPI:1629056577
Name:PETRA HEALTH, INC.
Entity Type:Organization
Organization Name:PETRA HEALTH, INC.
Other - Org Name:TOTAL HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTAZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-495-5493
Mailing Address - Street 1:10010 SAN PEDRO AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-3862
Mailing Address - Country:US
Mailing Address - Phone:210-495-5493
Mailing Address - Fax:210-491-4331
Practice Address - Street 1:10010 SAN PEDRO AVE
Practice Address - Street 2:STE 120
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-3862
Practice Address - Country:US
Practice Address - Phone:210-495-5493
Practice Address - Fax:210-491-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-02
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX013766251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX013766OtherHOME HEALTH LICENSE
TX013766OtherHOME HEALTH LICENSE
TX=========OtherTAX ID NUMBER