Provider Demographics
NPI:1750517793
Name:PROVIDIAN
Entity type:Organization
Organization Name:PROVIDIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:SHONDALE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-603-6643
Mailing Address - Street 1:402 KATY LN
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2302
Mailing Address - Country:US
Mailing Address - Phone:937-603-6643
Mailing Address - Fax:
Practice Address - Street 1:2844 E RIVER RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1538
Practice Address - Country:US
Practice Address - Phone:937-603-6643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MUSTARD SEED FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare