Provider Demographics
NPI:1790109437
Name:PROVIDENT HOME CARE, INC
Entity Type:Organization
Organization Name:PROVIDENT HOME CARE, INC
Other - Org Name:PROVIDENT HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ-SANTALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-264-2641
Mailing Address - Street 1:70 FLORAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1511
Mailing Address - Country:US
Mailing Address - Phone:908-264-2641
Mailing Address - Fax:
Practice Address - Street 1:70 FLORAL AVE
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1511
Practice Address - Country:US
Practice Address - Phone:908-264-2641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHP0184300251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health