Provider Demographics
NPI:1730950072
Name:PROVISION HOME
Entity type:Organization
Organization Name:PROVISION HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:BARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:APSS
Authorized Official - Phone:606-923-0361
Mailing Address - Street 1:778 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-1110
Mailing Address - Country:US
Mailing Address - Phone:606-923-0361
Mailing Address - Fax:
Practice Address - Street 1:778 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1110
Practice Address - Country:US
Practice Address - Phone:606-923-0361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty