Provider Demographics
NPI:1225586951
Name:PROVIDENCE HOSPICE INC
Entity Type:Organization
Organization Name:PROVIDENCE HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:YOSSI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-326-6010
Mailing Address - Street 1:440 N MOUNTAIN AVE STE 201G
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5183
Mailing Address - Country:US
Mailing Address - Phone:909-326-6010
Mailing Address - Fax:909-326-6011
Practice Address - Street 1:440 N MOUNTAIN AVE STE 201G
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5183
Practice Address - Country:US
Practice Address - Phone:909-326-6010
Practice Address - Fax:909-326-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3926029251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based