1881840932 NPI number — SOUTH BAY MANOR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881840932 NPI number — SOUTH BAY MANOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BAY MANOR
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:
1881840932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6737 W WASHINGTON ST
Provider Second Line Business Mailing Address:
SUITE 2300,
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-789-5880
Provider Business Mailing Address Fax Number:
401-783-2880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1959 KINGSTOWN ROAD
Provider Second Line Business Practice Location Address:
SOUTH BAY RETIREMENT LIVING
Provider Business Practice Location Address City Name:
SOUTH KINGSTOWN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-789-5880
Provider Business Practice Location Address Fax Number:
401-783-2880
Provider Enumeration Date:
08/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OHLENDORF
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER (CFO)
Authorized Official Telephone Number:
414-918-5403

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  LTC00735 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , 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)