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General NPI Number Information
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NPI Number | 1558660027
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Entity Type | Organization
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Legal Business Name | PROVIDENCE NURSING SERVICES
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 1008 W HONKER DR
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City | MERIDIAN
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State | ID
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Zip | 83642-7735
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Country | US
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Telephone | 208-413-3312
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Fax | 208-209-5123
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Provider Business Mailing Address
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Address Line | 1008 W HONKER DR
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City | MERIDIAN
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State | ID
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Zip | 83642-7735
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Country | US
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Telephone | 208-413-3312
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Fax | 208-209-5123
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MR. JACK G WATKINS JR.
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Credential | RN.
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Telephone | 208-413-3312
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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 | 603069327
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License Number State | ID
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