Healthcare Provider Details

I. General information

NPI: 1467583534
Provider Name (Legal Business Name): BLACKSTONE HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

426 MAIN ST
PAWTUCKET RI
02860-2912
US

IV. Provider business mailing address

426 MAIN ST
PAWTUCKET RI
02860-2912
US

V. Phone/Fax

Practice location:
  • Phone: 401-727-0950
  • Fax: 401-725-3053
Mailing address:
  • Phone: 401-727-0950
  • Fax: 401-725-3053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number13
License Number StateRI

VIII. Authorized Official

Name: MR. THOMAS GOUGH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 401-727-0950