| Name: | 642 METACOM AVENUE OPERATIONS LLC |
| Jurisdiction: | Rhode Island |
| Entity type: | Foreign Limited Liability Company |
| Status: | Activ |
| Date of Organization in Rhode Island: | 14 Aug 2008 (17 years ago) |
| Identification Number: | 000485359 |
| Place of Formation: | DELAWARE |
| Principal Address: | 101 EAST STATE STREET, KENNETT SQUARE, PA, 19348, USA |
| Mailing Address: | 101 E STATE STREET, KENNETT SQUARE, PA, 19348, USA |
| Purpose: | OPERATOR OF HEALTHCARE FACILITY |
| Fictitious names: |
Warren Skilled Nursing and Rehabilitation (trading name, 2008-08-27 - ) |
NAICS
623110 Nursing Care Facilities (Skilled Nursing Facilities)This industry comprises establishments primarily engaged in providing inpatient nursing and rehabilitative services. The care is generally provided for an extended period of time to individuals requiring nursing care. These establishments have a permanent core staff of registered or licensed practical nurses who, along with other staff, provide nursing and continuous personal care services. Learn more at the U.S. Census Bureau
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1265683874 | 2008-10-02 | 2024-01-22 | 642 METACOM AVE, WARREN, RI, 028852350, US | 642 METACOM AVE, WARREN, RI, 028852350, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 401-245-2860 |
| Fax | 4012450959 |
Authorized person
| Name | MICHAEL T BERG |
| Role | ASSISTANT SECRETARY |
| Phone | 5054684742 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | LTC00733 |
| State | RI |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | MA75166 |
| State | RI |
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY | Agent | 222 JEFFERSON BOULEVARD SUITE 200, WARWICK, RI, 02888, USA |
| Name | Role | Address |
|---|---|---|
| KEITH NAUSE | Manager | 101 E STATE STREET KENNETT SQUARE, PA 19348 USA |
| MICHAEL S SHERMAN | Manager | 101 E. STATE STREET KENNETT SQUARE, PA 19348 USA |
| STEPHEN S YOUNG | Manager | 101 E. STATE STREET KENNETT SQUARE, PA 19348 USA |
| MICHAEL BERG | Manager | 101 E. STATE STREET KENNETT SQUARE, PA 19348 USA |
| SEAN STEVENSON | Manager | 101 E STATE STREET KENNETT SQUARE, PA 19348 USA |
| Number | Name | File Date |
|---|---|---|
| 202450246830 | Annual Report | 2024-04-05 |
| 202331380170 | Annual Report | 2023-03-22 |
| 202220602060 | Annual Report | 2022-06-28 |
| 202219493220 | Revocation Notice For Failure to File An Annual Report | 2022-06-22 |
| 202102785650 | Annual Report | 2021-10-06 |
| 202066647650 | Annual Report | 2020-10-20 |
| 201924917670 | Annual Report | 2019-10-21 |
| 201879733190 | Annual Report | 2018-10-19 |
| 201751708210 | Annual Report | 2017-10-24 |
| 201752136490 | Amendment to Application for Registration | 2017-10-24 |
Date of last update: 13 Oct 2024
Sources: Rhode Island Department of State
