Provider Demographics
NPI:1104961242
Name:STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Entity type:Organization
Organization Name:STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-462-1343
Mailing Address - Street 1:1710 E WALLUM LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-1825
Mailing Address - Country:US
Mailing Address - Phone:401-567-0990
Mailing Address - Fax:401-567-0147
Practice Address - Street 1:1710 EAST WALLUM LAKE ROAD
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-1825
Practice Address - Country:US
Practice Address - Phone:401-567-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI48320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIEW12083Medicaid