Healthcare Provider Details

I. General information

NPI: 1144287491
Provider Name (Legal Business Name): JOHN D BOMFORD LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 ATWOOD AVE
JOHNSTON RI
02919
US

IV. Provider business mailing address

249 ROOSEVELT AVE STE 205
PAWTUCKET RI
02860
US

V. Phone/Fax

Practice location:
  • Phone: 401-553-1000
  • Fax:
Mailing address:
  • Phone: 401-724-8400
  • Fax: 701-365-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: