Provider Demographics
NPI:1063242568
Name:PROVIDENCE PLACE, LLC
Entity type:Organization
Organization Name:PROVIDENCE PLACE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:B
Authorized Official - Last Name:SYRIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-465-8019
Mailing Address - Street 1:100 LEONARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-9649
Mailing Address - Country:US
Mailing Address - Phone:828-464-8264
Mailing Address - Fax:
Practice Address - Street 1:630 WHITTIER AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-8049
Practice Address - Country:US
Practice Address - Phone:336-888-6760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-07
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility