Provider Demographics
NPI:1417954967
Name:CEDAR CREST NURSING CENTRE INC
Entity Type:Organization
Organization Name:CEDAR CREST NURSING CENTRE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WHIPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-944-8500
Mailing Address - Street 1:125 SCITUATE AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-1838
Mailing Address - Country:US
Mailing Address - Phone:401-944-8500
Mailing Address - Fax:401-944-6241
Practice Address - Street 1:125 SCITUATE AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02921-1838
Practice Address - Country:US
Practice Address - Phone:401-944-8500
Practice Address - Fax:401-944-6241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI669314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4105032Medicaid
RI415032Medicare ID - Type Unspecified