Healthcare Provider Details

I. General information

NPI: 1912265323
Provider Name (Legal Business Name): EMMA PENDLETON BRADLEY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

IV. Provider business mailing address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5640
  • Fax:
Mailing address:
  • Phone: 401-444-5640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberHOS00123
License Number StateRI

VIII. Authorized Official

Name: MRS. MAMIE WAKEFIELD
Title or Position: CFO
Credential: CPA
Phone: 401-444-5640