Provider Demographics
NPI:1639531197
Name:PROVISION HOME CARE SERVICES, LLC
Entity Type:Organization
Organization Name:PROVISION HOME CARE SERVICES, LLC
Other - Org Name:PROVISION HOME CARE SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DON/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARISELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:956-975-9264
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78599-0163
Mailing Address - Country:US
Mailing Address - Phone:956-854-4518
Mailing Address - Fax:956-854-4488
Practice Address - Street 1:617 S TEXAS BLVD, STE A
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596
Practice Address - Country:US
Practice Address - Phone:956-854-4518
Practice Address - Fax:956-854-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX017533251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362153402Medicaid
TX3621534Medicaid
TX362153401Medicaid