Healthcare Provider Details

I. General information

NPI: 1093832339
Provider Name (Legal Business Name): AVATAR RESIDENTIAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 NEW RIVER RD
MANVILLE RI
02838-1805
US

IV. Provider business mailing address

33 COLLEGE HILL RD BUILDING 33
WARWICK RI
02886-2776
US

V. Phone/Fax

Practice location:
  • Phone: 401-333-2851
  • Fax:
Mailing address:
  • Phone: 401-826-7500
  • Fax: 401-826-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number218
License Number StateRI

VIII. Authorized Official

Name: KATHLEEN A ELLIS
Title or Position: VICE PRESIDENT
Credential:
Phone: 401-826-7500