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General NPI Number Information
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NPI Number | 1457242463
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Entity Type | Organization
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Legal Business Name | PROVISIONAL 2 PREFERRED LIVING 4 EVER 62 INC.
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Dates
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Enumeration Date | 07/09/2025
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 3300 HENRY AVE APT 210
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City | PHILADELPHIA
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State | PA
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Zip | 19129-1151
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Country | US
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Telephone | 267-235-1839
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Fax |
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Provider Business Mailing Address
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Address Line | 711 ARNOLD ST
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City | PHILA
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State | PA
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Zip | 19111-1326
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Country | US
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Telephone | 267-235-1839
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | NINA BAKER
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Credential |
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Telephone | 267-235-1839
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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