Provider Demographics
NPI:1801000955
Name:PROVIDENCE CENTER, INC.
Entity Type:Organization
Organization Name:PROVIDENCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:COBLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:410-766-2212
Mailing Address - Street 1:930 POINT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-6604
Mailing Address - Country:US
Mailing Address - Phone:410-766-2212
Mailing Address - Fax:443-577-0215
Practice Address - Street 1:8223 CLOVERLEAF DR
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1534
Practice Address - Country:US
Practice Address - Phone:443-679-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDDA-4049-00251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services