Provider Demographics
NPI:1184714602
Name:FOREST FARM HEALTH CARE CENTER I LLC
Entity type:Organization
Organization Name:FOREST FARM HEALTH CARE CENTER I LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:H
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-847-2777
Mailing Address - Street 1:201 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-4625
Mailing Address - Country:US
Mailing Address - Phone:401-847-2777
Mailing Address - Fax:401-848-7403
Practice Address - Street 1:201 FOREST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-4625
Practice Address - Country:US
Practice Address - Phone:401-847-2777
Practice Address - Fax:401-848-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00737314000000X
RIALR01308310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIFF03657Medicaid
RIFF40453Medicaid
RI4105040Medicaid
RIFF40453Medicaid