Provider Demographics
NPI:1851728042
Name:PROVIDENCE SERVICE CORPORATION
Entity Type:Organization
Organization Name:PROVIDENCE SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOH-KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-221-6400
Mailing Address - Street 1:2215 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2215 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2663
Practice Address - Country:US
Practice Address - Phone:714-221-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health