MEDICARE: SHADY ACRES OPERATIONS ASSOC LLC

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	314000000X	Skilled Nursing Facility	LTC00804	RI

General Provider Information

NPI Number	:	1366997082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADY ACRES OPERATIONS ASSOC LLC

Provider Business Mailing Address
First Line	:	4770 WHITE PLAINS RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470
Country	:	US
Telephone Number	:	718-931-9700
Fax Number	:

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	:	MEMBER
Name	:	KENNETH ROZENBERG
Credential	:
Telephone Number	:	718-931-9700

Provider Enumeration Date	:	08/23/2016
Last Update Date	:	10/05/2016

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