Healthcare Provider Details

I. General information

NPI: 1093057143
Provider Name (Legal Business Name): 100 WAMPANOAG TRAIL OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WAMPANOAG TRL
RIVERSIDE RI
02915-3736
US

IV. Provider business mailing address

500 SENECA ST STE 100
BUFFALO NY
14204-1963
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-4275
  • Fax: 401-438-8093
Mailing address:
  • Phone: 716-633-3900
  • Fax: 646-924-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY RUBIN
Title or Position: CO-CHIEF EXECUTIVE OFFICER
Credential:
Phone: 716-817-5075