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  5. Hattie Ide Chaffee Nursing Home Inc

Hattie Ide Chaffee Nursing Home Inc

Company Details

Name: Hattie Ide Chaffee Nursing Home Inc
Jurisdiction: Rhode Island
Entity type: Domestic Non-Profit Corporation
Status: Activ
Date of Organization in Rhode Island: 23 Jun 1948 (77 years ago)
Identification Number: 000028527
ZIP code: 02915
County: Providence County
Principal Address: 200 WAMPANOAG TRAIL, RIVERSIDE, RI, 02915, USA
Purpose: LONG TERM NURSING HOME CARE
NAICS: 622310 - Specialty (except Psychiatric and Substance Abuse) Hospitals
Fictitious names: Hattie Ide Chaffee Home (trading name, 2022-09-20 - )
Historical names: Rhode Island Cancer Society Convalescent Home
Hattie Ide Chaffee Nursing Home

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1700912458 2007-02-26 2020-08-22 200 WAMPANOAG TRL, RIVERSIDE, RI, 029152206, US 200 WAMPANOAG TRL, RIVERSIDE, RI, 029152206, US

Contacts
Phone +1 401-434-1520
Fax 4014388494

Authorized person
Name MRS. DEBORAH M GRIFFIN
Role ADMINISTRATOR
Phone 4014341520

Taxonomy
Taxonomy Code 314000000X - Skilled Nursing Facility
License Number 223
State RI
Is Primary Yes

Other Provider Identifiers
Issuer UNITED HEALTHCARE
Number 71-09045
State RI
Issuer BLUE CROSS BLUE SHIELD
Number 5024-7
State RI
Issuer BLUE CHIP PROVIDER #
Number 401299
State RI
Issuer MEDICAID
Number 4105002
State RI

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
HATTIE IDE CHAFFEE 401(K) PLAN 2023 050258818 2024-10-10 HATTIE IDE CHAFFEE NURSING HOME 84
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2024-10-10
Name of individual signing BARRY ZELTZER
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2022 050258818 2023-10-03 HATTIE IDE CHAFFEE NURSING HOME 76
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2023-10-03
Name of individual signing BARRY ZELTZER
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2021 050258818 2022-10-12 HATTIE IDE CHAFFEE NURSING HOME 55
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2022-10-12
Name of individual signing BARRY ZELTZER
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2020 050258818 2021-09-29 HATTIE IDE CHAFFEE NURSING HOME 66
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2021-09-29
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2019 050258818 2020-09-28 HATTIE IDE CHAFFEE NURSING HOME 68
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2020-09-28
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2018 050258818 2019-10-10 HATTIE IDE CHAFFEE NURSING HOME 64
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2019-10-10
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2017 050258818 2018-10-09 HATTIE IDE CHAFFEE NURSING HOME 81
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915
HATTIE IDE CHAFFEE 401(K) PLAN 2016 050258818 2017-10-03 HATTIE IDE CHAFFEE NURSING HOME 94
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2017-10-03
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K) PLAN 2015 050258818 2017-10-03 HATTIE IDE CHAFFEE NURSING HOME 85
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2017-10-03
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
HATTIE IDE CHAFFEE 401(K)PLAN 2014 050258818 2015-10-14 HATTIE IDE CHAFFEE NURSING HOME 74
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2015-10-14
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2014/07/15/20140715122518P040039975703001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2014-07-15
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2013/10/09/20131009152546P030027446979001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Signature of
Role Plan administrator
Date 2013-10-09
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2012/10/01/20121001125826P030005275184001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915

Plan administrator’s name and address
Administrator’s EIN 050258818
Plan administrator’s name HATTIE IDE CHAFFEE NURSING HOME
Plan administrator’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915
Administrator’s telephone number 4014341520

Signature of
Role Plan administrator
Date 2012-10-01
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/09/27/20110927105009P040045945895001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206

Plan administrator’s name and address
Administrator’s EIN 050258818
Plan administrator’s name HATTIE IDE CHAFFEE NURSING HOME
Plan administrator’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206
Administrator’s telephone number 4014341520

Signature of
Role Plan administrator
Date 2011-09-27
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2010/09/13/20100913103322P070002535877001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2002-07-01
Business code 623000
Sponsor’s telephone number 4014341520
Plan sponsor’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206

Plan administrator’s name and address
Administrator’s EIN 050258818
Plan administrator’s name HATTIE IDE CHAFFEE NURSING HOME
Plan administrator’s address 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 029152206
Administrator’s telephone number 4014341520

Signature of
Role Plan administrator
Date 2010-09-13
Name of individual signing DEBORAH GRIFFIN
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
BARRY B. ZELTZER, PHD Agent 200 WAMPANOAG TRAIL, EAST PROVIDENCE, RI, 02915, USA

PRESIDENT

Name Role Address
DAVID R MATERNE PRESIDENT 6 DANA ROAD BARRINGTON, RI 02806 USA

TREASURER

Name Role Address
AMY GULDHAUGE TREASURER 60 CATAMORE BLVD EAST PROVIDENCE, RI 02914 USA

SECRETARY

Name Role Address
TEDFORD B RADWAY SECRETARY 1738 BROAD ST CRANSTON, RI 02905 USA

VICE PRESIDENT

Name Role Address
KAREN RICE VICE PRESIDENT 951 NORTH MAIN STREET PROVIDENCE, RI 02806 USA

DIRECTOR

Name Role Address
KIMBERLY SERRA DIRECTOR 735 WILLETT AVENUE RIVERSIDE, RI 02915 USA
SHARLEEN BOWEN DIRECTOR 172 NAYATT ROAD BARRINGTON, RI 02806 USA
MICHAEL REUTER DPM DIRECTOR 950 WARREN AVENUE EAST PROVIDENCE, RI 02915 USA
BENJAMIN CHWALK DIRECTOR 3 WOOLETT COURT BARRINGTON, RI 02806 USA
PETER J MINIATI DIRECTOR 9 ELIZABETH ROAD BARRINGTON, RI 02806 USA
CHRISTINA SCOLA DIRECTOR 301 PROMENADE STREET PROVIDENCE, RI 02908 USA
JAY GREGORY DIRECTOR 40 FAIRWAY DRIVE SEEKONK, RI 02771 USA

Events

Type Date Old Value New Value
Name Change 2019-12-04 Hattie Ide Chaffee Nursing Home Hattie Ide Chaffee Nursing Home Inc
Name Change 1950-04-10 Rhode Island Cancer Society Convalescent Home Hattie Ide Chaffee Nursing Home

Filings

Number Name File Date
202451685610 Annual Report 2024-04-19
202328404610 Annual Report 2023-02-15
202222913830 Fictitious Business Name Statement 2022-09-20
202219948450 Statement of Change of Registered/Resident Agent 2022-06-24
202212598580 Annual Report 2022-03-10
202197803280 Annual Report 2021-06-04
202042256140 Annual Report 2020-06-16
201929327500 Articles of Amendment 2019-12-04
201993631530 Annual Report 2019-05-20
201869485920 Annual Report 2018-06-13

Related by officers

AMY GULDHAUGE

Starkweather & Shepley Insurance Brokerage Incorporated Shepley Real Estate Holding Company, Inc. Rhode Island Nursing Home Group, Inc.

KAREN RICE

CompuCom Systems, Inc.

KIMBERLY SERRA

SERRA PHYSICAL THERAPY, LLC KMS REALTY, LLC

MICHAEL REUTER DPM

Rhode Island Podiatric Medical Association

Related by address

No related companies by address

Date of last update: 06 Oct 2024

Sources: Rhode Island Department of State

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