Healthcare Provider Details

I. General information

NPI: 1245763853
Provider Name (Legal Business Name): PROVIDENCE REHABILITATION AND HOSPICE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 RODGERS SCHOOL RD
WILLIAMSTON NC
27892-8246
US

IV. Provider business mailing address

4915 ARENDELL ST SUITE J-#323
MOREHEAD CITY NC
28557-2659
US

V. Phone/Fax

Practice location:
  • Phone: 800-279-1455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SIMONE GARDNER
Title or Position: CEO
Credential:
Phone: 252-217-8487