Basic Information
| Provider Information | |||||||||
| NPI: | 1275663221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-TOWN ECONOMIC OPPORTUNITY COMMITTEE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRI-TOWN COMMUNITY ACTION AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029197109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013512750 | ||||||||
| FaxNumber: | 4013516611 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 PUTNAM PIKE | ||||||||
| Address2: | ADULT DAY SERVICE BUILDING | ||||||||
| City: | GREENVILLE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028281428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019493890 | ||||||||
| FaxNumber: | 4019495666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DESANTIS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4013512750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRI-TOWN ECONOMIC OPPORTUNITY COMMITTEE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | 1 | RI | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | DC04475 | 05 | RI | MEDICAID |