Provider Demographics
NPI:1003649104
Name:PROVIDENCE HEALTH CARE AGENCY LLC
Entity type:Organization
Organization Name:PROVIDENCE HEALTH CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:QUARGNILDE
Authorized Official - Middle Name:
Authorized Official - Last Name:ILEKENDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-407-4242
Mailing Address - Street 1:2538 BAHAMA DR APT 238
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-2137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2538 BAHAMA DR APT 238
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-2137
Practice Address - Country:US
Practice Address - Phone:214-407-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty