Healthcare Provider Details

I. General information

NPI: 1821133505
Provider Name (Legal Business Name): BROADROCK ROAD GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BROAD ROCK RD
PEACE DALE RI
02879-1851
US

IV. Provider business mailing address

6 HARRINGTON RD
CRANSTON RI
02920-3080
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-6880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number122
License Number StateRI

VIII. Authorized Official

Name: MS. ELLEN R NELSON
Title or Position: DIRECTOR
Credential:
Phone: 401-462-6001