Provider Demographics
NPI:1881684736
Name:CHARLESGATE NURSING CENTER
Entity Type:Organization
Organization Name:CHARLESGATE NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSEMINO
Authorized Official - Suffix:
Authorized Official - Credentials:RN,NHA
Authorized Official - Phone:401-861-5858
Mailing Address - Street 1:100 RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2723
Mailing Address - Country:US
Mailing Address - Phone:401-861-5858
Mailing Address - Fax:401-861-2540
Practice Address - Street 1:100 RANDALL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2723
Practice Address - Country:US
Practice Address - Phone:401-861-5858
Practice Address - Fax:401-861-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILTC00621314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4105052Medicaid
RI4105052Medicaid
RI0924200001Medicare NSC