Healthcare Provider Details

I. General information

NPI: 1043722960
Provider Name (Legal Business Name): PROVIDENCE OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S WYCOMBE AVE
LANSDOWNE PA
19050-2835
US

IV. Provider business mailing address

PO BOX 1030
BRICK NJ
08723-0090
US

V. Phone/Fax

Practice location:
  • Phone: 610-626-8065
  • Fax:
Mailing address:
  • Phone: 732-903-1958
  • 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: MINDEE DRILLMAN
Title or Position: CONTROLLER
Credential: CPA
Phone: 732-903-1958