Provider Demographics
NPI:1700105426
Name:PROVIDENCE HOME
Entity Type:Organization
Organization Name:PROVIDENCE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAAGHE
Authorized Official - Middle Name:MMBI
Authorized Official - Last Name:FOGWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-715-0236
Mailing Address - Street 1:8108 MODESTO DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-8545
Mailing Address - Country:US
Mailing Address - Phone:817-715-0236
Mailing Address - Fax:
Practice Address - Street 1:8108 MODESTO DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-8545
Practice Address - Country:US
Practice Address - Phone:817-715-0236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities