Provider Demographics
NPI:1134276975
Name:PROVIDENCE PROFESSIONAL SERVICES GROUP INC
Entity type:Organization
Organization Name:PROVIDENCE PROFESSIONAL SERVICES GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LENIHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-470-6399
Mailing Address - Street 1:6555 NW 36 ST
Mailing Address - Street 2:STE 105
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:786-470-6399
Mailing Address - Fax:
Practice Address - Street 1:6555 NW 36 ST
Practice Address - Street 2:STE 105
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:786-470-6399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty