Provider Demographics
NPI:1821567991
Name:PROVIDENCE
Entity Type:Organization
Organization Name:PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-395-7602
Mailing Address - Street 1:17 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483-4868
Mailing Address - Country:US
Mailing Address - Phone:601-395-7602
Mailing Address - Fax:
Practice Address - Street 1:17 DAISY LN
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-4868
Practice Address - Country:US
Practice Address - Phone:601-395-7602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800427553172A00000X
MS8000427553343900000X
MS098765347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate VehicleGroup - Single Specialty