1154466522 NPI number — MOONSTONE BEACH RD GROUP HOME

Table of content: (NPI 1154466522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154466522 NPI number — MOONSTONE BEACH RD GROUP HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOONSTONE BEACH RD GROUP HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154466522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 HARRINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02920-3080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-462-2659
Provider Business Mailing Address Fax Number:
401-462-6631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
446 MOONSTONE BEACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-5110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-782-8480
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
401-462-6001

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  26 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MB04412 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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