Provider Demographics
NPI:1780807347
Name:ETHAN PLACE
Entity type:Organization
Organization Name:ETHAN PLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LACROSS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:401-781-5460
Mailing Address - Street 1:85 ETHAN ST
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3905
Mailing Address - Country:US
Mailing Address - Phone:401-781-5460
Mailing Address - Fax:401-781-0479
Practice Address - Street 1:85 ETHAN ST
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3905
Practice Address - Country:US
Practice Address - Phone:401-781-5460
Practice Address - Fax:401-781-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI207261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI=========Medicare UPIN