Healthcare Provider Details

I. General information

NPI: 1366997082
Provider Name (Legal Business Name): SHADY ACRES OPERATIONS ASSOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 GARDNER RD
WEST KINGSTON RI
02892-1047
US

IV. Provider business mailing address

4770 WHITE PLAINS RD
BRONX NY
10470
US

V. Phone/Fax

Practice location:
  • Phone: 401-295-8520
  • Fax: 401-294-1050
Mailing address:
  • Phone: 718-931-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberLTC00804
License Number StateRI

VIII. Authorized Official

Name: KENNETH ROZENBERG
Title or Position: MEMBER
Credential:
Phone: 718-931-9700