Provider Demographics
NPI:1235697426
Name:PROVISIONAM
Entity type:Organization
Organization Name:PROVISIONAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLINE
Authorized Official - Middle Name:PIERRE-LOUIS
Authorized Official - Last Name:CENATUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-404-9870
Mailing Address - Street 1:2280 SUNFLOWER ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77713-9214
Mailing Address - Country:US
Mailing Address - Phone:239-404-9870
Mailing Address - Fax:
Practice Address - Street 1:3819 PHELAN BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2243
Practice Address - Country:US
Practice Address - Phone:409-363-5022
Practice Address - Fax:409-363-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0OtherWAITING FOR MEDICARE NUMBER