Basic Information
Provider Information | |||||||||
NPI: | 1184875791 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 70 GILL AVENUE OPERATIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PAWTUCKET SKILLED NURSING AND REHABILITATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 70 GILL AVE | ||||||||
Address2: |   | ||||||||
City: | PAWTUCKET | ||||||||
State: | RI | ||||||||
PostalCode: | 028614315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017227900 | ||||||||
FaxNumber: | 4017239670 | ||||||||
Practice Location | |||||||||
Address1: | 70 GILL AVE | ||||||||
Address2: |   | ||||||||
City: | PAWTUCKET | ||||||||
State: | RI | ||||||||
PostalCode: | 028614315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017227900 | ||||||||
FaxNumber: | 4017239670 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2008 | ||||||||
LastUpdateDate: | 07/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERG | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CORPORATE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5054684742 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | LTC00736 | RI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | GA75165 | 05 | RI |   | MEDICAID |