Provider Demographics
NPI:1265683874
Name:642 METACOM AVENUE OPERATIONS LLC
Entity Type:Organization
Organization Name:642 METACOM AVENUE OPERATIONS LLC
Other - Org Name:WARREN SKILLED NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:642 METACOM AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:RI
Mailing Address - Zip Code:02885-2350
Mailing Address - Country:US
Mailing Address - Phone:401-245-2860
Mailing Address - Fax:401-245-0959
Practice Address - Street 1:642 METACOM AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-2350
Practice Address - Country:US
Practice Address - Phone:401-245-2860
Practice Address - Fax:401-245-0959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILTC00733314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMA75166Medicaid