Healthcare Provider Details

I. General information

NPI: 1598267429
Provider Name (Legal Business Name): JONATHAN R TEOLI MSPO CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1559 ELMWOOD AVE
CRANSTON RI
02910-3845
US

IV. Provider business mailing address

1559 ELMWOOD AVE
CRANSTON RI
02910-3845
US

V. Phone/Fax

Practice location:
  • Phone: 401-941-6230
  • Fax: 401-941-6339
Mailing address:
  • Phone: 401-941-6230
  • Fax: 401-941-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: