Provider Demographics
NPI:1659651560
Name:SH OPCO EAST BAY MANOR LLC
Entity Type:Organization
Organization Name:SH OPCO EAST BAY MANOR LLC
Other - Org Name:EAST BAY RETIREMENT LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:OHLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5000
Mailing Address - Street 1:1440 WAMPANOAG TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1045
Mailing Address - Country:US
Mailing Address - Phone:401-433-5000
Mailing Address - Fax:401-433-4541
Practice Address - Street 1:1440 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-1045
Practice Address - Country:US
Practice Address - Phone:401-433-5000
Practice Address - Fax:401-433-4541
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RITBDMedicaid