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General NPI Number Information
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NPI Number | 1780807347
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Entity Type | Organization
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Legal Business Name | ETHAN PLACE
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 85 ETHAN ST
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City | WARWICK
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State | RI
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Zip | 02888-3905
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Country | US
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Telephone | 401-781-5460
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Fax | 401-781-0479
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Provider Business Mailing Address
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Address Line | 85 ETHAN ST
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City | WARWICK
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State | RI
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Zip | 02888-3905
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Country | US
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Telephone | 401-781-5460
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Fax | 401-781-0479
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. SANDRA L. LACROSS
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Credential | RN
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Telephone | 401-781-5460
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0800X
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Taxonomy Name | Recovery Care Clinic/Center
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License Number | 207
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License Number State | RI
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