Provider Demographics
NPI:1659659811
Name:PROVISIONAL HOME HEALTH LLC
Entity Type:Organization
Organization Name:PROVISIONAL HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:763-575-7281
Mailing Address - Street 1:4110 MAPLE HURST DR S
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55373-4565
Mailing Address - Country:US
Mailing Address - Phone:763-575-7281
Mailing Address - Fax:
Practice Address - Street 1:4110 MAPLE HURST DR S
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MN
Practice Address - Zip Code:55373-4565
Practice Address - Country:US
Practice Address - Phone:763-575-7281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN353499251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health