Basic Information
| Provider Information | |||||||||
| NPI: | 1376596114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOME HEALTH PROVIDENCE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION AT HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CADILLAC DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370271001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178414834 | ||||||||
| FaxNumber: | 8669558538 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 OWEN LANE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767107919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545236970 | ||||||||
| FaxNumber: | 2547618787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ADKINS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6153095668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 016737 | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 112810002 | 05 | TX | MEDICAID |