Provider Demographics
NPI:1639408453
Name:PROVISIONS HHS, INC
Entity type:Organization
Organization Name:PROVISIONS HHS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ FOUNDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:PETTWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-428-3726
Mailing Address - Street 1:1027 S RAINBOW BLVD
Mailing Address - Street 2:#207
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-6232
Mailing Address - Country:US
Mailing Address - Phone:702-428-3726
Mailing Address - Fax:
Practice Address - Street 1:1027 S RAINBOW BLVD
Practice Address - Street 2:#207
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-6232
Practice Address - Country:US
Practice Address - Phone:702-428-3726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV251E00000XMedicaid