Healthcare Provider Details

I. General information

NPI: 1639333495
Provider Name (Legal Business Name): PROVIDENCE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8544 PARK HIGHLAND DR
ORLANDO FL
32818-5770
US

IV. Provider business mailing address

8544 PARK HIGHLAND DR
ORLANDO FL
32818-5770
US

V. Phone/Fax

Practice location:
  • Phone: 407-953-5657
  • Fax:
Mailing address:
  • Phone: 407-953-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL10413
License Number StateFL

VIII. Authorized Official

Name: VERONICA LAWRENCE-POKIMA
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-953-5657