Basic Information
| Provider Information | |||||||||
| NPI: | 1427177005 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNISTER NURSING CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 DODGE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029072210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015219600 | ||||||||
| FaxNumber: | 4012743233 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 DODGE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029072210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015219600 | ||||||||
| FaxNumber: | 4012743233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MANCINI | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4015219600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3140N1450X | LTC00600 | RI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 4105038 | 05 | RI | MEDICAID | 5005-0 | 01 | RI | BLUE CROSS | OTHER |