Provider Demographics
NPI:1982735247
Name:ROCKY KNOLL GROUP HOME, INC.
Entity Type:Organization
Organization Name:ROCKY KNOLL GROUP HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARVALHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-624-6359
Mailing Address - Street 1:3709 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-4854
Mailing Address - Country:US
Mailing Address - Phone:401-624-6359
Mailing Address - Fax:401-624-8383
Practice Address - Street 1:3709 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-4854
Practice Address - Country:US
Practice Address - Phone:401-624-6359
Practice Address - Fax:401-624-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI7251C00000X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRK61536Medicaid