Provider Demographics
NPI:1780640169
Name:PROVIDENT SENIOR HEALTH, INC.
Entity Type:Organization
Organization Name:PROVIDENT SENIOR HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOONING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-493-5270
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80151-0060
Mailing Address - Country:US
Mailing Address - Phone:303-493-5270
Mailing Address - Fax:303-493-5295
Practice Address - Street 1:799 E HAMPDEN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2700
Practice Address - Country:US
Practice Address - Phone:303-493-5270
Practice Address - Fax:303-493-5295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25175025Medicaid
CO25175025Medicaid