Provider Demographics
NPI:1598368235
Name:TAVARES PEDIATRIC CENTER
Entity Type:Organization
Organization Name:TAVARES PEDIATRIC CENTER
Other - Org Name:TAVARES PEDIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIN ADM
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-272-7127
Mailing Address - Street 1:101 PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4828
Mailing Address - Country:US
Mailing Address - Phone:401-272-7127
Mailing Address - Fax:401-272-4752
Practice Address - Street 1:101 PLAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4828
Practice Address - Country:US
Practice Address - Phone:401-272-7127
Practice Address - Fax:401-272-4752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities