Provider Demographics
NPI:1710212352
Name:PROVIDENCE ACADEMY FOR STUDENT SUCCESS
Entity Type:Organization
Organization Name:PROVIDENCE ACADEMY FOR STUDENT SUCCESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:DONYALE
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-866-7277
Mailing Address - Street 1:4300 KIMBERLY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232
Mailing Address - Country:US
Mailing Address - Phone:614-866-7277
Mailing Address - Fax:614-866-8494
Practice Address - Street 1:4300 KIMBERLY PKWY N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-8296
Practice Address - Country:US
Practice Address - Phone:614-866-7277
Practice Address - Fax:614-866-8494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)