Provider Demographics
NPI:1467962043
Name:PROVIDENTIAL SOLUTIONS, LLC
Entity Type:Organization
Organization Name:PROVIDENTIAL SOLUTIONS, LLC
Other - Org Name:PROVIDENTIAL HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:ATANO
Authorized Official - Last Name:OSIMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-998-9978
Mailing Address - Street 1:1 RIDER MILL CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-2472
Mailing Address - Country:US
Mailing Address - Phone:410-998-9978
Mailing Address - Fax:443-381-0483
Practice Address - Street 1:1 RIDER MILL CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-2472
Practice Address - Country:US
Practice Address - Phone:410-998-9978
Practice Address - Fax:443-381-0483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2235253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5709600300Medicaid