1245593268 NPI number — PROVIDENCE SERVICE, LLC

Table of content: (NPI 1245593268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245593268 NPI number — PROVIDENCE SERVICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE SERVICE, LLC
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 SERVICE, LLC
Provider Other Organization Name Type Code:
3
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:
1245593268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2530 W ALLENS PEAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUEEN CREEK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85142-4642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-668-4485
Provider Business Mailing Address Fax Number:
480-812-3133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2530 W ALLENS PEAK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85142-4642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-668-4485
Provider Business Practice Location Address Fax Number:
480-812-3131
Provider Enumeration Date:
06/25/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OSINLOYE
Authorized Official First Name:
OLAYINKA
Authorized Official Middle Name:
O
Authorized Official Title or Position:
FNP/PMHNP
Authorized Official Telephone Number:
615-668-4485

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  APN0000015886 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1524996 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z181765 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".