Provider Demographics
NPI:1093057143
Name:100 WAMPANOAG TRAIL OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:100 WAMPANOAG TRAIL OPERATING COMPANY, LLC
Other - Org Name:ELDERWOOD AT RIVERSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-817-5075
Mailing Address - Street 1:500 SENECA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-1963
Mailing Address - Country:US
Mailing Address - Phone:716-633-3900
Mailing Address - Fax:646-924-0502
Practice Address - Street 1:100 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-3736
Practice Address - Country:US
Practice Address - Phone:401-438-4275
Practice Address - Fax:401-438-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
415007Medicare Oscar/Certification