Healthcare Provider Details

I. General information

NPI: 1235455239
Provider Name (Legal Business Name): PROVIDENTIAL HEALTH CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 SUTTON PARK DR S SUITE 1101
JACKSONVILLE FL
32224-0236
US

IV. Provider business mailing address

13400 SUTTON PARK DR S SUITE 1101
JACKSONVILLE FL
32224-0236
US

V. Phone/Fax

Practice location:
  • Phone: 904-992-2273
  • Fax: 904-992-2270
Mailing address:
  • Phone: 904-992-2273
  • Fax: 904-992-2270

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: LYDIA FLORENCE MWESIGWA
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 214-240-6146