Provider Demographics
NPI:1376805630
Name:PROVIDENCE CARE INC
Entity Type:Organization
Organization Name:PROVIDENCE CARE INC
Other - Org Name:PROVIDENCE PRIVATE CARE HOME AND PROVIDENCE COMMUNITY LIVING ARRANGEM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:NGOZI
Authorized Official - Last Name:OKPALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-931-7854
Mailing Address - Street 1:216 NW BROAD ST STE B
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4106
Mailing Address - Country:US
Mailing Address - Phone:678-489-2069
Mailing Address - Fax:678-489-8627
Practice Address - Street 1:216 NW BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4106
Practice Address - Country:US
Practice Address - Phone:678-489-2069
Practice Address - Fax:678-489-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-R-1019251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health