Healthcare Provider Details

I. General information

NPI: 1588157341
Provider Name (Legal Business Name): PROVIDENT GROUP - CANTON COVE PROPERTIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REINHARDT COLLEGE PARKWAY
CANTON GA
30114
US

IV. Provider business mailing address

5565 BANKERS AVENUE
BATON ROUGE LA
70808
US

V. Phone/Fax

Practice location:
  • Phone: 770-721-2812
  • Fax: 770-721-5701
Mailing address:
  • Phone: 225-766-3977
  • Fax: 225-766-3988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: DEBRA W. LOCKWOOD
Title or Position: PRESIDENT & CHIEF FINANCIAL OFFICER
Credential:
Phone: 225-766-3977