Provider Demographics
NPI:1740599240
Name:PROVIDIAN TOTAL HEALTH LLC
Entity Type:Organization
Organization Name:PROVIDIAN TOTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IHEKORONYE
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:832-512-3234
Mailing Address - Street 1:718 MISTYCREEK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:832-615-0813
Practice Address - Street 1:618 TRAVIS ST
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77520-7568
Practice Address - Country:US
Practice Address - Phone:832-512-3234
Practice Address - Fax:832-615-0813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities