Provider Demographics
NPI:1205918166
Name:PRUDENTIAL HEALTH CARE SERVICES INC
Entity type:Organization
Organization Name:PRUDENTIAL HEALTH CARE SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMPSON
Authorized Official - Middle Name:
Authorized Official - Last Name:OHONBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-417-0227
Mailing Address - Street 1:7011 LAKE ROBERTS WAY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-4041
Mailing Address - Country:US
Mailing Address - Phone:817-608-0455
Mailing Address - Fax:
Practice Address - Street 1:7011 LAKE ROBERTS WAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-4041
Practice Address - Country:US
Practice Address - Phone:817-608-0455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009477251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013960Medicaid
TX457926Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER