Healthcare Provider Details

I. General information

NPI: 1619615689
Provider Name (Legal Business Name): PROVIDENT SENIOR SOLUTIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 14TH ST MODESTO, CA 95354
MODESTO CA
95354-9535
US

IV. Provider business mailing address

PO BOX 3558
MODESTO CA
95352-3558
US

V. Phone/Fax

Practice location:
  • Phone: 209-595-4421
  • Fax:
Mailing address:
  • Phone: 120-957-8121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: ROBIN D CONLEY
Title or Position: PRESIDENT/CEO
Credential: RN
Phone: 209-578-1210