Provider Demographics
NPI:1043496706
Name:PROVIDENCE ADULT DAY CARE CENTER, INC.
Entity Type:Organization
Organization Name:PROVIDENCE ADULT DAY CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:RODGERS
Authorized Official - Last Name:ELEY
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:410-523-1500
Mailing Address - Street 1:1427 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3135
Mailing Address - Country:US
Mailing Address - Phone:410-523-1500
Mailing Address - Fax:
Practice Address - Street 1:1427 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3135
Practice Address - Country:US
Practice Address - Phone:410-523-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care