Healthcare Provider Details

I. General information

NPI: 1457610552
Provider Name (Legal Business Name): 198 WATERMAN AVENUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 WATERMAN AVE
EAST PROVIDENCE RI
02914-3523
US

IV. Provider business mailing address

198 WATERMAN AVE
EAST PROVIDENCE RI
02914-3523
US

V. Phone/Fax

Practice location:
  • Phone: 401-751-3800
  • Fax:
Mailing address:
  • Phone: 401-751-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: KELLY ARNOLD
Title or Position: COO
Credential:
Phone: 401-751-3800