Provider Demographics
NPI:1902101488
Name:PROVIDENCE NOBLE CARE INC
Entity type:Organization
Organization Name:PROVIDENCE NOBLE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PROVIDENTIA
Authorized Official - Middle Name:NJIDEKA
Authorized Official - Last Name:IGBOELUSI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:239-368-2507
Mailing Address - Street 1:2606 64TH ST W
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-0859
Mailing Address - Country:US
Mailing Address - Phone:239-368-2507
Mailing Address - Fax:239-368-2507
Practice Address - Street 1:2606 64TH ST W
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-0859
Practice Address - Country:US
Practice Address - Phone:239-368-2507
Practice Address - Fax:239-368-2507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL089327385HR2060X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL688753896Medicaid
FL688753801Medicaid