Provider Demographics
NPI:1477748614
Name:PROVIDENCE HEALTHCARE SERVICES, INC.
Entity type:Organization
Organization Name:PROVIDENCE HEALTHCARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NERCY
Authorized Official - Middle Name:
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-220-1088
Mailing Address - Street 1:10250 SW 56TH ST STE D103
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-7065
Mailing Address - Country:US
Mailing Address - Phone:305-220-1088
Mailing Address - Fax:305-220-1086
Practice Address - Street 1:10250 SW 56TH ST STE D103
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7065
Practice Address - Country:US
Practice Address - Phone:305-220-1088
Practice Address - Fax:305-220-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299992862251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL299992862OtherHOME HEALTH AGENCY
FL10-9065Medicare PIN