Basic Information
| Provider Information | |||||||||
| NPI: | 1912158528 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 10 WOODLAND DRIVE OPERATIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | RESPIRATORY AND REHABILITATION CENTER OF RHODE ISLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COVENTRY | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028166716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018262000 | ||||||||
| FaxNumber: | 4018210260 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COVENTRY | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028166716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018262000 | ||||||||
| FaxNumber: | 4018210260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684742 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | LTC00732 | RI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | WD75163 | 05 | RI | MEDICAID |