Provider Demographics
NPI:1174986608
Name:THEODORE J HARDGROVE
Entity type:Organization
Organization Name:THEODORE J HARDGROVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HARDGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-749-7088
Mailing Address - Street 1:174 WOODWARD ROAD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-749-7088
Mailing Address - Fax:
Practice Address - Street 1:174 WOODWARD RD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1720
Practice Address - Country:US
Practice Address - Phone:401-749-7088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1024143314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility