Provider Demographics
NPI:1821698374
Name:PROCTORS PROVISION LLC.
Entity Type:Organization
Organization Name:PROCTORS PROVISION LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:TA'SHEA
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-814-8528
Mailing Address - Street 1:1809 VANDIVER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-3948
Mailing Address - Country:US
Mailing Address - Phone:573-814-8528
Mailing Address - Fax:
Practice Address - Street 1:1809 VANDIVER DR STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-3948
Practice Address - Country:US
Practice Address - Phone:573-814-8528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health