Provider Demographics
NPI:1366442899
Name:THE TAVARES PEDIATRIC CENTER INC
Entity type:Organization
Organization Name:THE TAVARES PEDIATRIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:F
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED
Authorized Official - Phone:401-272-7127
Mailing Address - Street 1:101 PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4824
Mailing Address - Country:US
Mailing Address - Phone:401-272-7127
Mailing Address - Fax:401-272-4752
Practice Address - Street 1:101 PLAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4824
Practice Address - Country:US
Practice Address - Phone:401-272-7127
Practice Address - Fax:401-272-4752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI 642315P00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI41G085Medicaid