Provider Demographics
NPI:1902047285
Name:PROVIDENCE HEALTH SERVICES OF WACO, INC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SERVICES OF WACO, INC
Other - Org Name:PROVIDENCE MEDICAL EQUIPMENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ODIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:254-751-4000
Mailing Address - Street 1:540 MEADOWLAKE CENTER
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712
Mailing Address - Country:US
Mailing Address - Phone:254-741-2495
Mailing Address - Fax:254-741-2496
Practice Address - Street 1:6600 FISH POND ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-741-2495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH SERVICES OF WACO, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-16
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0160434-01Medicaid
0444390005Medicare NSC