Provider Demographics
NPI:1275157000
Name:PROVIDENT HEALTH PARTNERS INC.
Entity Type:Organization
Organization Name:PROVIDENT HEALTH PARTNERS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DESOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-266-4501
Mailing Address - Street 1:554 LARKFIELD RD STE 207
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-4205
Mailing Address - Country:US
Mailing Address - Phone:631-266-4501
Mailing Address - Fax:631-266-4502
Practice Address - Street 1:1529 N OCEAN AVE STE A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3587
Practice Address - Country:US
Practice Address - Phone:631-266-4501
Practice Address - Fax:631-266-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center