=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568103919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE PERSONAL CARE PPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2022
-----------------------------------------------------
Last Update Date | 04/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1317 EDGEWATER DR # 4354
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-335-4327
-----------------------------------------------------
Fax | 407-789-3637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1317 EDGEWATER DR # 4354
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-335-4327
-----------------------------------------------------
Fax | 407-789-3637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MANAGER
-----------------------------------------------------
Name | JULIET DONNA PROVIDENCE
-----------------------------------------------------
Credential | CNA- RNA
-----------------------------------------------------
Telephone | 424-206-0650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------