Healthcare Provider Details

I. General information

NPI: 1568978690
Provider Name (Legal Business Name): LIFESTYLE MEDICINE OF RHODE ISLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 ATWOOD AVE STE 336
JOHNSTON RI
02919-3228
US

IV. Provider business mailing address

1524 ATWOOD AVE STE 336
JOHNSTON RI
02919-3228
US

V. Phone/Fax

Practice location:
  • Phone: 401-228-6844
  • Fax: 401-228-6855
Mailing address:
  • Phone: 401-228-6844
  • Fax: 401-228-6855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberMD04110
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberMD04110
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD04110
License Number StateRI

VIII. Authorized Official

Name: MRS. MARTHA MARY FONTAINE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 401-228-6844