Provider Demographics
NPI:1538253307
Name:PROVIDENCE PLACE ASSISTED LIVING, INC.
Entity type:Organization
Organization Name:PROVIDENCE PLACE ASSISTED LIVING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-888-4568
Mailing Address - Street 1:1701 WESTCHESTER DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262
Mailing Address - Country:US
Mailing Address - Phone:336-888-4568
Mailing Address - Fax:336-888-4663
Practice Address - Street 1:630 WHITTIER AVENUE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7602
Practice Address - Country:US
Practice Address - Phone:336-888-6777
Practice Address - Fax:336-888-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL041047310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804713Medicaid