Provider Demographics
NPI:1760508501
Name:GREATER PROVIDENCE CHAPTER,RIARC
Entity Type:Organization
Organization Name:GREATER PROVIDENCE CHAPTER,RIARC
Other - Org Name:JOHN E. FOGARTY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:BS,CPP
Authorized Official - Phone:401-353-6990
Mailing Address - Street 1:220 WOONASQUATUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-3196
Mailing Address - Country:US
Mailing Address - Phone:401-353-6990
Mailing Address - Fax:401-353-0290
Practice Address - Street 1:2 TESTA CIR
Practice Address - Street 2:
Practice Address - City:NORTH SCITUATE
Practice Address - State:RI
Practice Address - Zip Code:02857-1870
Practice Address - Country:US
Practice Address - Phone:401-647-2779
Practice Address - Fax:401-353-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI53315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJF02844Medicaid