Provider Demographics
NPI:1245593268
Name:PROVIDENCE SERVICE, LLC
Entity Type:Organization
Organization Name:PROVIDENCE SERVICE, LLC
Other - Org Name:PROVIDENCE SERVICE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP/PMHNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLAYINKA
Authorized Official - Middle Name:O
Authorized Official - Last Name:OSINLOYE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:615-668-4485
Mailing Address - Street 1:2530 W ALLENS PEAK DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-4642
Mailing Address - Country:US
Mailing Address - Phone:615-668-4485
Mailing Address - Fax:480-812-3133
Practice Address - Street 1:2530 W ALLENS PEAK DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-4642
Practice Address - Country:US
Practice Address - Phone:615-668-4485
Practice Address - Fax:480-812-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000015886261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524996Medicaid
AZZ181765Medicaid