Healthcare Provider Details

I. General information

NPI: 1144864463
Provider Name (Legal Business Name): PROVIDENTIAL CARES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 ELAM RD
PAMPLIN VA
23958-3242
US

IV. Provider business mailing address

281 ELAM RD
PAMPLIN VA
23958-3242
US

V. Phone/Fax

Practice location:
  • Phone: 434-574-2247
  • Fax: 434-574-2028
Mailing address:
  • Phone: 434-574-2247
  • Fax: 434-574-2028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: LEWIS WATSON SR.
Title or Position: OWNER
Credential:
Phone: 434-574-2247