Healthcare Provider Details

I. General information

NPI: 1265683874
Provider Name (Legal Business Name): 642 METACOM AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 METACOM AVE
WARREN RI
02885-2350
US

IV. Provider business mailing address

642 METACOM AVE
WARREN RI
02885-2350
US

V. Phone/Fax

Practice location:
  • Phone: 401-245-2860
  • Fax: 401-245-0959
Mailing address:
  • Phone: 401-245-2860
  • Fax: 401-245-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberLTC00733
License Number StateRI

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742