Healthcare Provider Details

I. General information

NPI: 1033755327
Provider Name (Legal Business Name): PROVIDENTIAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 KNUTH RD STE 212B
BOYNTON BEACH FL
33436-4636
US

IV. Provider business mailing address

200 KNUTH RD STE 212B
BOYNTON BEACH FL
33436-4636
US

V. Phone/Fax

Practice location:
  • Phone: 561-460-1717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA DUFORT
Title or Position: SECRETARY
Credential:
Phone: 561-707-3030