Provider Demographics
NPI:1669968152
Name:PROVISION HEALTHCARE, LLC
Entity type:Organization
Organization Name:PROVISION HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LASHONDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:803-302-8205
Mailing Address - Street 1:4611 HARD SCRABBLE RD STE 178
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8584
Mailing Address - Country:US
Mailing Address - Phone:803-302-8205
Mailing Address - Fax:
Practice Address - Street 1:1320 MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3266
Practice Address - Country:US
Practice Address - Phone:803-373-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-08
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBL015940-07-2018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty