Provider Demographics
NPI:1235277260
Name:PROVIDENCE CARE
Entity Type:Organization
Organization Name:PROVIDENCE CARE
Other - Org Name:HUNTER HILL SENIOR VILLAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOROWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:RICE
Authorized Official - Last Name:REDGRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-443-7144
Mailing Address - Street 1:891 NOELL LN
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1742
Mailing Address - Country:US
Mailing Address - Phone:252-443-7144
Mailing Address - Fax:252-443-2319
Practice Address - Street 1:891 NOELL LN
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1742
Practice Address - Country:US
Practice Address - Phone:252-443-7144
Practice Address - Fax:252-443-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL064016310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805571Medicaid