Provider Demographics
NPI:1881840932
Name:SOUTH BAY MANOR
Entity Type:Organization
Organization Name:SOUTH BAY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER (CFO)
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:OHLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5403
Mailing Address - Street 1:6737 W WASHINGTON ST
Mailing Address - Street 2:SUITE 2300,
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214
Mailing Address - Country:US
Mailing Address - Phone:401-789-5880
Mailing Address - Fax:401-783-2880
Practice Address - Street 1:1959 KINGSTOWN ROAD
Practice Address - Street 2:SOUTH BAY RETIREMENT LIVING
Practice Address - City:SOUTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02879-1608
Practice Address - Country:US
Practice Address - Phone:401-789-5880
Practice Address - Fax:401-783-2880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI310400000X
RILTC00735313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility