MEDICARE: SHADY ACRES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	608	RI
2	314000000X	Skilled Nursing Facility	608	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	402416	OTHER	RI	BLUE CHIP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	71-0005	OTHER	RI	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1346234135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADY ACRES, INC.

Provider Business Mailing Address
First Line	:	415 GARDNER RD
Second Line	:
City	:	WEST KINGSTON
State	:	RI
Zip	:	02892-1047
Country	:	US
Telephone Number	:	401-295-8520
Fax Number	:	401-294-1050

Provider Business Practice Location Address
First Line	:	415 GARDNER RD
Second Line	:
City	:	WEST KINGSTON
State	:	RI
Zip	:	02892-1047
Country	:	US
Telephone Number	:	401-295-8520
Fax Number	:	401-294-1050

Authorized Official
Title or Position	:	PRESIDENT/ADMINISTRATOR
Name	:	MR. CHARLES WILLIAM MIGA
Credential	:
Telephone Number	:	401-295-8540

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	09/10/2014

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Directions to “SHADY ACRES, INC. ” Practice Location

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