Organization Name: | EAST WALLUM LAKE GROUP HOME |
NPI Number: | 1104961242 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | CRAIG S STENNING (DIRECTOR) |
Mailing Address: | 1710 East Wallum Lake Road Pascoag |
State: | RI US |
Postal Code: | 028591825 |
Phone Number: | 4015670990 |
Fax Number: | |
NPI Enumeration Date: | 02/20/2007 |
NPI Last Update Date: | 10/27/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 320900000X |
License Number: | 48 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | RI |
Taxonomy Type: | Residential Treatment Facilities |
Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
Taxonomy Specialization: | |
Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |