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General NPI Number Information
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NPI Number | 1093057143
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Entity Type | Organization
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Legal Business Name | 100 WAMPANOAG TRAIL OPERATING COMPANY, LLC
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Dates
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Enumeration Date | 03/26/2013
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Last Update Date | 01/19/2023
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Provider Practice Location Address
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Address Line | 100 WAMPANOAG TRL
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City | RIVERSIDE
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State | RI
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Zip | 02915-3736
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Country | US
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Telephone | 401-438-4275
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Fax | 401-438-8093
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Provider Business Mailing Address
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Address Line | 500 SENECA ST STE 100
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City | BUFFALO
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State | NY
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Zip | 14204-1963
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Country | US
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Telephone | 716-633-3900
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Fax | 646-924-0502
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Authorized Official
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Title or Position | CO-CHIEF EXECUTIVE OFFICER
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Name | DR. JEFFREY RUBIN
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Credential |
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Telephone | 716-817-5075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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