Provider Demographics
NPI:1770856072
Name:PROVIDENCE HEALTHCARE
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NERCY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-282-1257
Mailing Address - Street 1:8505 NW 74TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-2327
Mailing Address - Country:US
Mailing Address - Phone:305-220-1088
Mailing Address - Fax:305-220-1086
Practice Address - Street 1:8505 NW 74TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166-2327
Practice Address - Country:US
Practice Address - Phone:305-220-1088
Practice Address - Fax:305-220-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherEIN