1801064118 NPI number — PROVIDENCE PLACE, INC

Table of content: (NPI 1801064118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801064118 NPI number — PROVIDENCE PLACE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE PLACE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROVIDENCE PLACE FAMILY CARE HOME
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801064118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
156 WOLFSNARE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27560-7061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-650-1725
Provider Business Mailing Address Fax Number:
919-767-9137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
916 CLAYTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27703-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-767-9037
Provider Business Practice Location Address Fax Number:
919-767-9037
Provider Enumeration Date:
02/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OLANREWAJU
Authorized Official First Name:
MOSES
Authorized Official Middle Name:
OLADAPO
Authorized Official Title or Position:
CEO/ADMINISTRATOR
Authorized Official Telephone Number:
919-767-9037

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  MHL-032-422 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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