Provider Demographics
NPI:1174026736
Name:PROVIDENCE CARE INC
Entity Type:Organization
Organization Name:PROVIDENCE CARE INC
Other - Org Name:PROVIDENCE CARE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMPLICIUS
Authorized Official - Middle Name:E
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:734-394-7679
Mailing Address - Street 1:808 BRISTOL DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-8329
Mailing Address - Country:US
Mailing Address - Phone:734-394-7679
Mailing Address - Fax:
Practice Address - Street 1:808 BRISTOL DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-8329
Practice Address - Country:US
Practice Address - Phone:734-394-7679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN220042163WH0200X, 163WP0808X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251J00000XAgenciesNursing Care
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty