Provider Demographics
NPI:1558660027
Name:PROVIDENCE NURSING SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE NURSING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:G
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:RN
Authorized Official - Phone:208-413-3312
Mailing Address - Street 1:1008 W HONKER DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7735
Mailing Address - Country:US
Mailing Address - Phone:208-413-3312
Mailing Address - Fax:208-209-5123
Practice Address - Street 1:1008 W HONKER DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7735
Practice Address - Country:US
Practice Address - Phone:208-413-3312
Practice Address - Fax:208-209-5123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID603069327251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID615764900OtherDOL CARE PROVIDER NUMBER.