NPIMap

Organization Active NPI

State of Rhode Island and Providence Plantations

Doing business as East Wallum Lake Group Home

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Pascoag, RI
National Provider Identifier
1104961242
Registry record updated Aug 22, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X
License
48 Issued in RI
Legal business name
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Doing business as
East Wallum Lake Group Home
Practice address
1710 East Wallum Lake Road
Pascoag, RI 02859-1825
Phone
(401) 567-0990
NPI assigned
Feb 20, 2007
Last updated
Aug 22, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Jennifer Rae White
Title
Deputy Cfo
Phone
(401) 462-1343

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility 320900000X 48 RI Primary

Addresses

Primary practice location

1710 East Wallum Lake Road
Pascoag, RI 02859-1825

Mailing address

1710 E Wallum Lake Rd
Pascoag, RI 02859-1825
Phone (401) 567-0990

Other identifiers 1

IdentifierTypeStateIssuer
EW12083MedicaidRI

Other names 1

  • East Wallum Lake Group Home Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Rhode Island Veterans Home65 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 21

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 21

Locations

1710 E Wallum Lake Rd
Pascoag, RI 02859
Phone (401) 567-0990

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171929600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1566432000000",
    "number": "1104961242",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1710 E WALLUM LAKE RD",
            "city": "PASCOAG",
            "state": "RI",
            "postal_code": "028591825",
            "telephone_number": "401-567-0990",
            "fax_number": "401-567-0147"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1710 EAST WALLUM LAKE ROAD",
            "city": "PASCOAG",
            "state": "RI",
            "postal_code": "028591825",
            "telephone_number": "401-567-0990"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-20",
        "last_updated": "2019-08-22",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "RAE",
        "authorized_official_title_or_position": "DEPUTY CFO",
        "authorized_official_telephone_number": "401-462-1343",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "RI",
            "license": "48",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "EW12083",
            "state": "RI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "East Wallum Lake Group Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pascoag, RI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.