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General NPI Number Information
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NPI Number | 1417298894
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Entity Type | Organization
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Legal Business Name | PROVIDENT CARE
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Dates
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Enumeration Date | 03/08/2013
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Last Update Date | 03/08/2013
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Provider Practice Location Address
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Address Line | 100 SYCAMORE AVE
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City | MODESTO
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State | CA
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Zip | 95354-0500
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Country | US
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Telephone | 209-578-1210
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3558
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City | MODESTO
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State | CA
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Zip | 95352-3558
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Country | US
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Telephone | 209-578-1210
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Fax | 209-549-9364
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Authorized Official
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Title or Position | CEO
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Name | MRS. ROBIN D CONLEY
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Credential | RN
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Telephone | 209-578-1210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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