Provider Demographics
NPI:1457242463
Name:PROVISIONAL 2 PREFERRED LIVING 4 EVER 62 INC.
Entity type:Organization
Organization Name:PROVISIONAL 2 PREFERRED LIVING 4 EVER 62 INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-235-1839
Mailing Address - Street 1:711 ARNOLD ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-1326
Mailing Address - Country:US
Mailing Address - Phone:267-235-1839
Mailing Address - Fax:
Practice Address - Street 1:3300 HENRY AVE APT 210
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1151
Practice Address - Country:US
Practice Address - Phone:267-235-1839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-09
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care