Provider Demographics
NPI:1750046777
Name:DE VINE PRIMARY HOME CARE LLC
Entity Type:Organization
Organization Name:DE VINE PRIMARY HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE ANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-890-0222
Mailing Address - Street 1:3003 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-2074
Mailing Address - Country:US
Mailing Address - Phone:956-890-0222
Mailing Address - Fax:
Practice Address - Street 1:1524 N CONWAY AVE
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-4003
Practice Address - Country:US
Practice Address - Phone:956-890-0222
Practice Address - Fax:956-598-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-04
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001032089Medicaid