Provider Demographics
NPI:1245763853
Name:PROVIDENCE REHABILITATION AND HOSPICE SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE REHABILITATION AND HOSPICE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-217-8487
Mailing Address - Street 1:4915 ARENDELL ST
Mailing Address - Street 2:SUITE J-#323
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2515 RODGERS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-8246
Practice Address - Country:US
Practice Address - Phone:800-279-1455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No251G00000XAgenciesHospice Care, Community Based
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health