Healthcare Provider Details

I. General information

NPI: 1902101488
Provider Name (Legal Business Name): PROVIDENCE NOBLE CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 64TH ST W
LEHIGH ACRES FL
33971-0859
US

IV. Provider business mailing address

2606 64TH ST W
LEHIGH ACRES FL
33971-0859
US

V. Phone/Fax

Practice location:
  • Phone: 239-368-2507
  • Fax: 239-368-2507
Mailing address:
  • Phone: 239-368-2507
  • Fax: 239-368-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number089327
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number089327
License Number StateFL

VIII. Authorized Official

Name: MS. PROVIDENTIA NJIDEKA IGBOELUSI
Title or Position: PRESIDENT
Credential: MBA
Phone: 239-368-2507