Provider Demographics
NPI:1063132876
Name:PROVIDENCE PLACE LLC
Entity type:Organization
Organization Name:PROVIDENCE PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-415-1313
Mailing Address - Street 1:249 JOE NAIA RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-4112
Mailing Address - Country:US
Mailing Address - Phone:912-415-1313
Mailing Address - Fax:
Practice Address - Street 1:249 JOE NAIA RD
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-4112
Practice Address - Country:US
Practice Address - Phone:912-415-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PLACE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities