Healthcare Provider Details

I. General information

NPI: 1902000102
Provider Name (Legal Business Name): PROVIDENCE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19140 S 3RD ST
CITRONELLE AL
36522-2306
US

IV. Provider business mailing address

PO BOX 850489
MOBILE AL
36685-0489
US

V. Phone/Fax

Practice location:
  • Phone: 251-866-0086
  • Fax: 251-866-0089
Mailing address:
  • Phone: 251-342-3949
  • Fax: 251-631-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CLARK P. CHRISTIANSON
Title or Position: PRESIDENT
Credential:
Phone: 251-631-3574