Healthcare Provider Details

I. General information

NPI: 1700397643
Provider Name (Legal Business Name): OCEAN STATE ACADEMY CRANSTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 ELMWOOD AVE
CRANSTON RI
02910-2204
US

IV. Provider business mailing address

285 BLOOMFIELD AVE STE 201
CALDWELL NJ
07006-5144
US

V. Phone/Fax

Practice location:
  • Phone: 401-423-4234
  • Fax:
Mailing address:
  • Phone: 973-287-6094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY JOSEPH CLANCY
Title or Position: DIRECTOR
Credential:
Phone: 401-423-4234