Provider Demographics
NPI:1902670854
Name:1ST PROVIDENCE HEALTH CARE SERVICES LLC
Entity Type:Organization
Organization Name:1ST PROVIDENCE HEALTH CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KORKOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-334-0571
Mailing Address - Street 1:1549 OLD BRIDGE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2737
Mailing Address - Country:US
Mailing Address - Phone:571-334-0571
Mailing Address - Fax:
Practice Address - Street 1:1549 OLD BRIDGE RD STE 208
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2737
Practice Address - Country:US
Practice Address - Phone:571-334-0571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-10
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty