Provider Demographics
NPI:1801954466
Name:PROVIDENT HOME HEALTH, INC.
Entity type:Organization
Organization Name:PROVIDENT HOME HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-241-9500
Mailing Address - Street 1:5015 EAGLE ROCK BLVD STE 309A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-2085
Mailing Address - Country:US
Mailing Address - Phone:818-241-9500
Mailing Address - Fax:818-241-9509
Practice Address - Street 1:5015 EAGLE ROCK BLVD STE 309A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-2085
Practice Address - Country:US
Practice Address - Phone:818-241-9500
Practice Address - Fax:818-241-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001477251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08286FMedicaid
058286Medicare Oscar/Certification