Healthcare Provider Details

I. General information

NPI: 1225543754
Provider Name (Legal Business Name): OCEAN STATE PRIMARY CARE CENTER OF EAST PROVIDENCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 VETERANS MEMORIAL PKWY UNIT 15B
EAST PROVIDENCE RI
02914-5300
US

IV. Provider business mailing address

2130 MENDON RD STE 3-333
CUMBERLAND RI
02864-3844
US

V. Phone/Fax

Practice location:
  • Phone: 401-434-3350
  • Fax:
Mailing address:
  • Phone: 401-353-1012
  • Fax: 401-353-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ZUBA
Title or Position: GENERAL MANAGER
Credential:
Phone: 401-626-2748