Healthcare Provider Details

I. General information

NPI: 1043496706
Provider Name (Legal Business Name): PROVIDENCE ADULT DAY CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 PENNSYLVANIA AVE
BALTIMORE MD
21217-3135
US

IV. Provider business mailing address

1427 PENNSYLVANIA AVE
BALTIMORE MD
21217-3135
US

V. Phone/Fax

Practice location:
  • Phone: 410-523-1500
  • Fax:
Mailing address:
  • Phone: 410-523-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMD

VIII. Authorized Official

Name: MS. STACY RODGERS ELEY
Title or Position: BOARD PRESIDENT
Credential: MPA
Phone: 410-523-1500