Healthcare Provider Details

I. General information

NPI: 1700616208
Provider Name (Legal Business Name): PROVIDENCE PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 WESTCHESTER DR
HIGH POINT NC
27262-7008
US

IV. Provider business mailing address

100 LEONARD AVE
NEWTON NC
28658-9649
US

V. Phone/Fax

Practice location:
  • Phone: 828-464-8264
  • Fax:
Mailing address:
  • Phone: 828-464-8264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: LEE B SYRIA
Title or Position: PRESIDENT/CEO
Credential:
Phone: 828-465-8019