Provider Demographics
NPI:1457047037
Name:PROVIDENCE HEALTH CARE SERVICES
Entity type:Organization
Organization Name:PROVIDENCE HEALTH CARE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:KENYANYA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:612-456-2773
Mailing Address - Street 1:781 103RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4507
Mailing Address - Country:US
Mailing Address - Phone:612-456-2773
Mailing Address - Fax:763-374-4469
Practice Address - Street 1:781 103RD AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4507
Practice Address - Country:US
Practice Address - Phone:612-456-2773
Practice Address - Fax:763-374-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility