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General NPI Number Information
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NPI Number | 1518320373
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Entity Type | Organization
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Legal Business Name | PROVIDENCE CORPORATION
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Dates
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Enumeration Date | 03/30/2016
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Last Update Date | 05/26/2016
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Provider Practice Location Address
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Address Line | 7928 RIDGE AVE FIRST FLOOR
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City | PHILADELPHIA
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State | PA
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Zip | 19128-3011
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Country | US
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Telephone | 484-746-0064
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Fax |
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Provider Business Mailing Address
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Address Line | 7928 RIDGE AVE FIRST FLOOR
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City | PHILADELPHIA
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State | PA
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Zip | 19128-3011
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Country | US
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Telephone | 484-746-0064
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ELVIRA N BERRY
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Credential | JD
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Telephone | 484-746-0064
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | CER-00092467
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | CER-00092467
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | CER-00092467
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License Number State | PA
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