Provider Demographics
NPI:1508208877
Name:PROVIDENT PLACE
Entity Type:Organization
Organization Name:PROVIDENT PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:APARICIO
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:626-722-1352
Mailing Address - Street 1:964 E BADILLO ST # 523
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2950
Mailing Address - Country:US
Mailing Address - Phone:626-722-1352
Mailing Address - Fax:626-966-0650
Practice Address - Street 1:15448 MONDAMON RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-4557
Practice Address - Country:US
Practice Address - Phone:760-242-4908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities