Provider Demographics
NPI:1093038929
Name:PROVIDENCE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCREA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-246-4446
Mailing Address - Street 1:3708 MAYFAIR ST
Mailing Address - Street 2:100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6226
Mailing Address - Country:US
Mailing Address - Phone:919-246-4426
Mailing Address - Fax:
Practice Address - Street 1:3708 MAYFAIR ST
Practice Address - Street 2:100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6226
Practice Address - Country:US
Practice Address - Phone:919-246-4426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-06
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health