Provider Demographics
NPI:1912313628
Name:PROVIDER HOME CARE
Entity Type:Organization
Organization Name:PROVIDER HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-799-1097
Mailing Address - Street 1:3832 MONTEVISTA
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3832 MONTEVISTA
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:PROVINCE
Practice Address - Zip Code:OHIO
Practice Address - Country:GE
Practice Address - Phone:216-799-1097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHFDW1871146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNIKE1234Medicaid
OHNIKE1234Medicare PIN