Provider Demographics
NPI:1700193562
Name:PROVIDENCE HOME CARE LLC
Entity Type:Organization
Organization Name:PROVIDENCE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-602-3295
Mailing Address - Street 1:4334 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 176
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1578
Mailing Address - Country:US
Mailing Address - Phone:405-602-3295
Mailing Address - Fax:
Practice Address - Street 1:4334 NW EXPRESSWAY
Practice Address - Street 2:SUITE 176
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1578
Practice Address - Country:US
Practice Address - Phone:405-602-3295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health