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General NPI Number Information
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NPI Number | 1265683874
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Entity Type | Organization
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Legal Business Name | 642 METACOM AVENUE OPERATIONS LLC
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Dates
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Enumeration Date | 10/02/2008
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Last Update Date | 01/22/2024
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Provider Practice Location Address
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Address Line | 642 METACOM AVE
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City | WARREN
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State | RI
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Zip | 02885-2350
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Country | US
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Telephone | 401-245-2860
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Fax | 401-245-0959
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Provider Business Mailing Address
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Address Line | 642 METACOM AVE
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City | WARREN
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State | RI
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Zip | 02885-2350
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Country | US
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Telephone | 401-245-2860
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Fax | 401-245-0959
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Authorized Official
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Title or Position | ASSISTANT SECRETARY
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Name | MICHAEL T BERG
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Credential |
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Telephone | 505-468-4742
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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 | LTC00733
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License Number State | RI
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