Provider Demographics
NPI:1962400317
Name:PROVIDENCE CARE CENTER, LLC
Entity type:Organization
Organization Name:PROVIDENCE CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-963-9150
Mailing Address - Street 1:209 SIGMA DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2826
Mailing Address - Country:US
Mailing Address - Phone:412-963-9150
Mailing Address - Fax:412-963-6676
Practice Address - Street 1:900 3RD AVE
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-4613
Practice Address - Country:US
Practice Address - Phone:724-846-8504
Practice Address - Fax:724-847-7927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA425002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1383OtherSECURITY BLUE
PA0018363330001Medicaid
PA217007OtherUPMC FOR YOU PROVIDER NO.
PA251144OtherHEALTH AMERICA
PA1035476OtherGATEWAY PROVIDER NUMBER
PA251144OtherHEALTH ASSURANCE
PA000000095232OtherUNISON (MED PLUS)
PA2058628OtherUS HEALTHCARE PROVIDER NO
PA506655OtherAETNA PROVIDER NUMBER
PA1383OtherBLUE CROSS PROVIDER NO.
PA251144OtherHEALTH AMERICA