Provider Demographics
NPI:1861902793
Name:PROVISTA HOME CARE LLC
Entity type:Organization
Organization Name:PROVISTA HOME CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BEATRIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:PUENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-965-0431
Mailing Address - Street 1:4849 GREENVILLE AVE STE 1124
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-4130
Mailing Address - Country:US
Mailing Address - Phone:214-965-0431
Mailing Address - Fax:214-965-0434
Practice Address - Street 1:4849 GREENVILLE AVE STE 1124
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-4130
Practice Address - Country:US
Practice Address - Phone:214-965-0431
Practice Address - Fax:214-965-0434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health