Provider Demographics
NPI:1043896905
Name:PROVIDENCE HOMECARE LLC
Entity type:Organization
Organization Name:PROVIDENCE HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NERCY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-220-1088
Mailing Address - Street 1:10250 SW 56TH ST STE D101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-7065
Mailing Address - Country:US
Mailing Address - Phone:305-220-1088
Mailing Address - Fax:
Practice Address - Street 1:10250 SW 56TH ST STE D101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7065
Practice Address - Country:US
Practice Address - Phone:305-220-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOMECARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102544500Medicaid