Healthcare Provider Details

I. General information

NPI: 1760508501
Provider Name (Legal Business Name): GREATER PROVIDENCE CHAPTER,RIARC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2 TESTA CIR
NORTH SCITUATE RI
02857-1870
US

IV. Provider business mailing address

220 WOONASQUATUCKET AVE
NORTH PROVIDENCE RI
02911-3196
US

V. Phone/Fax

Practice location:
  • Phone: 401-647-2779
  • Fax: 401-353-0290
Mailing address:
  • Phone: 401-353-6990
  • Fax: 401-353-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number53
License Number StateRI

VIII. Authorized Official

Name: MR. JOHN COSTA
Title or Position: CONTROLLER
Credential: BS,CPP
Phone: 401-353-6990