Provider Demographics
NPI:1982030193
Name:PROVIDENCE HOME MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:PROVIDENCE HOME MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:CPCO
Authorized Official - Phone:205-221-8258
Mailing Address - Street 1:406 MEDICAL CENTER DR.
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-3400
Mailing Address - Country:US
Mailing Address - Phone:205-221-8200
Mailing Address - Fax:205-221-8270
Practice Address - Street 1:6701 AIRPORT BLVD.
Practice Address - Street 2:STE. B-121
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6705
Practice Address - Country:US
Practice Address - Phone:251-633-7491
Practice Address - Fax:251-633-7492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL163809Medicaid