Healthcare Provider Details

I. General information

NPI: 1144773623
Provider Name (Legal Business Name): CAVICCHIO PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WAKE ROBIN RD UNIT 203
LINCOLN RI
02865-4295
US

IV. Provider business mailing address

2 WAKE ROBIN RD UNIT 203
LINCOLN RI
02865-4295
US

V. Phone/Fax

Practice location:
  • Phone: 401-312-9999
  • Fax: 401-312-0416
Mailing address:
  • Phone: 401-312-9999
  • Fax: 401-312-0416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberDPM 206
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDPM 206
License Number StateRI

VIII. Authorized Official

Name: DR. CHARLES M CAVICCHIO
Title or Position: OWNER
Credential: DPM
Phone: 401-312-9999