Healthcare Provider Details

I. General information

NPI: 1720011018
Provider Name (Legal Business Name): WAMPANOAG MEDICAL CLINIC & TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 PAWTUCKET AVE
EAST PROVIDENCE RI
02914-1718
US

IV. Provider business mailing address

1970 PAWTUCKET AVE
EAST PROVIDENCE RI
02914-1718
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-6620
  • Fax: 401-438-6621
Mailing address:
  • Phone: 401-438-6620
  • Fax: 401-438-6621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberMD4452
License Number StateRI

VIII. Authorized Official

Name: DR. JUANITO A ABANILLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 401-438-6620