Provider Demographics
NPI:1972362796
Name:THE PROVIDENCIA GROUP
Entity type:Organization
Organization Name:THE PROVIDENCIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-223-4629
Mailing Address - Street 1:7773 WAIKAPU LOOP
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-3026
Mailing Address - Country:US
Mailing Address - Phone:808-282-1840
Mailing Address - Fax:
Practice Address - Street 1:19775 BELMONT EXECUTIVE PLZ STE 450
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7606
Practice Address - Country:US
Practice Address - Phone:571-431-1458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty