Provider Demographics
NPI:1053706812
Name:PROVIDENCE COMMUNITY SERVICE LLC
Entity type:Organization
Organization Name:PROVIDENCE COMMUNITY SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-674-1044
Mailing Address - Street 1:7011 EGAN PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-8310
Mailing Address - Country:US
Mailing Address - Phone:804-674-1044
Mailing Address - Fax:804-674-1110
Practice Address - Street 1:7011 EGAN PL
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-8310
Practice Address - Country:US
Practice Address - Phone:804-674-1044
Practice Address - Fax:804-674-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA225301001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities