Provider Demographics
NPI:1962876334
Name:PROVIDENCE HOUSE ELDERCARE SERVICES
Entity type:Organization
Organization Name:PROVIDENCE HOUSE ELDERCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-822-2386
Mailing Address - Street 1:25 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03868-8449
Mailing Address - Country:US
Mailing Address - Phone:207-459-4521
Mailing Address - Fax:
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03868-8449
Practice Address - Country:US
Practice Address - Phone:207-459-4521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-22
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04108310400000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care