Healthcare Provider Details

I. General information

NPI: 1669690418
Provider Name (Legal Business Name): CRANSTON PEDIATRICS LLC DBA PARK PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PARK AVE
CRANSTON RI
02910-2036
US

IV. Provider business mailing address

801 PARK AVE
CRANSTON RI
02910-2036
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-6575
  • Fax: 401-273-2597
Mailing address:
  • Phone: 401-274-6575
  • Fax: 401-273-2597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD11641
License Number StateRI

VIII. Authorized Official

Name: DR. RICK MANUEL QUILES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 401-274-6575