Provider Demographics
NPI:1124601000
Name:PROVIDENCE HOME AND COMMUNITY LIVING SERVICE
Entity Type:Organization
Organization Name:PROVIDENCE HOME AND COMMUNITY LIVING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-791-6041
Mailing Address - Street 1:907 INMAN RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-3009
Mailing Address - Country:US
Mailing Address - Phone:901-791-6041
Mailing Address - Fax:
Practice Address - Street 1:907 INMAN RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-3009
Practice Address - Country:US
Practice Address - Phone:901-791-6041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health