Provider Demographics
NPI:1982853131
Name:PROVIDENT HEALTH CARE L.L.C
Entity Type:Organization
Organization Name:PROVIDENT HEALTH CARE L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:TIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-723-4888
Mailing Address - Street 1:4092 ST TROPEZ CT
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-9539
Mailing Address - Country:US
Mailing Address - Phone:209-723-4888
Mailing Address - Fax:
Practice Address - Street 1:1238 CATALINA DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-9515
Practice Address - Country:US
Practice Address - Phone:408-828-6527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N.A313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility