| Organization Name: | PROVIDENTIAL FACILITY SERVICES, LLC |
| NPI Number: | 1144510157 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOSEPH COY RANDOLPF (OWNER) |
| Mailing Address: | 611 Ford St Greenville |
| State: | NC US |
| Postal Code: | 278342935 |
| Phone Number: | 2529022617 |
| Fax Number: | |
| NPI Enumeration Date: | 04/11/2011 |
| NPI Last Update Date: | 04/11/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320600000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental disabilities and/or mental retardation and are not able to live independently. |