Provider Demographics
NPI:1518320373
Name:PROVIDENCE CORPORATION
Entity Type:Organization
Organization Name:PROVIDENCE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELVIRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:484-746-0064
Mailing Address - Street 1:7928 RIDGE AVE
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3011
Mailing Address - Country:US
Mailing Address - Phone:484-746-0064
Mailing Address - Fax:
Practice Address - Street 1:7928 RIDGE AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3011
Practice Address - Country:US
Practice Address - Phone:484-746-0064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACER-00092467251S00000X, 311ZA0620X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities