1710222534 NPI number — PROVIDENCE SERVICE CORPORATION

Table of content: (NPI 1710222534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710222534 NPI number — PROVIDENCE SERVICE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE SERVICE CORPORATION
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:
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:
1710222534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 758866
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21275-8866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-373-0620
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 DAVENPORT CIR
Provider Second Line Business Practice Location Address:
SUITE 4; ACHIEVE PROGRAM
Provider Business Practice Location Address City Name:
BATH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04530-2880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-443-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ZENGA
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
207-373-0620

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  392123 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 191700000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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