Provider Demographics
NPI:1811219942
Name:PROVIDENCE GROUP HOME
Entity type:Organization
Organization Name:PROVIDENCE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:POLYCARP
Authorized Official - Middle Name:ANAYO
Authorized Official - Last Name:OHAKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-680-9144
Mailing Address - Street 1:3327 CHAPELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-4005
Mailing Address - Country:US
Mailing Address - Phone:214-680-9144
Mailing Address - Fax:972-226-7935
Practice Address - Street 1:1047 HILLBURN DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4328
Practice Address - Country:US
Practice Address - Phone:214-680-9144
Practice Address - Fax:972-226-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health