Healthcare Provider Details

I. General information

NPI: 1881840932
Provider Name (Legal Business Name): SOUTH BAY MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 KINGSTOWN ROAD SOUTH BAY RETIREMENT LIVING
SOUTH KINGSTOWN RI
02879-1608
US

IV. Provider business mailing address

6737 W WASHINGTON ST SUITE 2300,
MILWAUKEE WI
53214
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-5880
  • Fax: 401-783-2880
Mailing address:
  • Phone: 401-789-5880
  • Fax: 401-783-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberLTC00735
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateRI

VIII. Authorized Official

Name: MARK OHLENDORF
Title or Position: CHIEF FINANCIAL OFFICER (CFO)
Credential:
Phone: 414-918-5403