Provider Demographics
NPI:1972119568
Name:PETRA HOME CARE LLC
Entity Type:Organization
Organization Name:PETRA HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHOWUNMI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:631-741-0795
Mailing Address - Street 1:4518 KNIGHT LAKE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-7982
Mailing Address - Country:US
Mailing Address - Phone:281-942-2670
Mailing Address - Fax:
Practice Address - Street 1:4518 KNIGHT LAKE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-7982
Practice Address - Country:US
Practice Address - Phone:281-942-2670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care