Provider Demographics
NPI:1558411942
Name:PROVIDENCE PLACE, INC.
Entity Type:Organization
Organization Name:PROVIDENCE PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:OLADAPO
Authorized Official - Last Name:OLANREWAJU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-767-9037
Mailing Address - Street 1:156 WOLFSNARE LN
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7061
Mailing Address - Country:US
Mailing Address - Phone:919-768-1090
Mailing Address - Fax:919-768-1090
Practice Address - Street 1:916 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2608
Practice Address - Country:US
Practice Address - Phone:919-767-9037
Practice Address - Fax:919-768-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-422320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities