=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801478748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALCYON AT WEST BAY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2021
-----------------------------------------------------
Last Update Date | 04/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2783 W SHORE RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02889-8659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-491-8721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2783 W SHORE RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02889-8659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-491-8721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MRS. CHARITY ANN STACKHOUSE
-----------------------------------------------------
Credential | LNHA
-----------------------------------------------------
Telephone | 740-491-8721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------