Healthcare Provider Details

I. General information

NPI: 1922143304
Provider Name (Legal Business Name): NICHOLS LANE GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 NICHOLS LN
WESTERLY RI
02891-1308
US

IV. Provider business mailing address

6 HARRINGTON RD
CRANSTON RI
02920-3080
US

V. Phone/Fax

Practice location:
  • Phone: 401-348-8087
  • Fax:
Mailing address:
  • Phone: 401-462-2659
  • Fax: 401-462-6631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number17
License Number StateRI

VIII. Authorized Official

Name: MS. ELLEN R NELSON
Title or Position: DIRECTOR
Credential:
Phone: 401-462-6001