Provident Care Residential Home LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

PROVIDENT CARE RESIDENTIAL HOME LLC

Practice address

4170 Mutter Rd
Saint Cloud, FL 34769-6836

Phone

(407) 556-3406

Fax

(407) 556-3406

NPI assigned

Dec 28, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Nadine Ellis-McIntyre

Title

Administrator

Phone

(321) 443-5470

Specialties & licenses 1

Addresses

Other names 1

• PROVIDENT HOUSE Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1609113600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1609113600000",
    "number": "1578150397",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4170 MUTTER RD",
            "city": "SAINT CLOUD",
            "state": "FL",
            "postal_code": "347696836",
            "telephone_number": "407-556-3406",
            "fax_number": "407-556-3406"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4170 MUTTER RD",
            "city": "SAINT CLOUD",
            "state": "FL",
            "postal_code": "347696836",
            "telephone_number": "407-556-3406",
            "fax_number": "407-556-3406"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENT CARE RESIDENTIAL HOME LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-28",
        "last_updated": "2020-12-28",
        "certification_date": "2020-12-28",
        "status": "A",
        "authorized_official_last_name": "ELLIS-MCINTYRE",
        "authorized_official_first_name": "NADINE",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "321-443-5470"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENT HOUSE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Assisted Living Facility in Saint Cloud, FL
• Providers in Saint Cloud, FL by specialty
• Assisted Living Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.