Healthcare Provider Details

I. General information

NPI: 1538343454
Provider Name (Legal Business Name): PROVIDENCE NURSING AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652B PARK AVE
WORCESTER MA
01603
US

IV. Provider business mailing address

652B PARK AVE
WORCESTER MA
01603
US

V. Phone/Fax

Practice location:
  • Phone: 508-798-2324
  • Fax: 508-798-2344
Mailing address:
  • Phone: 508-798-2324
  • Fax: 508-798-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number251E00000X
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. CARMEN VANHORNE
Title or Position: PRESIDENT
Credential:
Phone: 508-798-2324