1689934085 NPI number — PROVIDENCE HEALTHCARE SERVICES INC

Table of content: (NPI 1689934085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689934085 NPI number — PROVIDENCE HEALTHCARE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTHCARE SERVICES 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:
Provider Other Organization Name Type Code:
6
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:
1689934085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36685-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-342-3949
Provider Business Mailing Address Fax Number:
251-631-3361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6701 AIRPORT BLVD
Provider Second Line Business Practice Location Address:
SUITE C132
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-6705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-631-3501
Provider Business Practice Location Address Fax Number:
251-631-3504
Provider Enumeration Date:
05/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTIANSON
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
251-633-1660

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  1-071676 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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