| 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 (16 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 |
| NAICS: | 623110 - Nursing Care Facilities (Skilled Nursing Facilities) |
| Fictitious names: |
Warren Skilled Nursing and Rehabilitation (trading name, 2008-08-27 - ) |
| 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 | |||||||||||||||||||||||||
|
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| 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
