MEDICARE: PROVIDENCE PROFESSIONAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		KS

General Provider Information

NPI Number	:	1851439095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE PROFESSIONAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	302 FLEMING ST
Second Line	:	SUITE #8
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6162
Country	:	US
Telephone Number	:	620-275-7100
Fax Number	:	620-275-7116

Provider Business Practice Location Address
First Line	:	302 FLEMING ST
Second Line	:	SUITE #8
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6162
Country	:	US
Telephone Number	:	620-275-7100
Fax Number	:	620-275-7116

Authorized Official
Title or Position	:	OWNER
Name	:	SANDRA FINE
Credential	:
Telephone Number	:	620-275-7100

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	08/22/2020

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