Healthcare Provider Details

I. General information

NPI: 1639404635
Provider Name (Legal Business Name): PROVIDENT PAIN AND WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 FRIENDSHIP ST SUITE 160
NEWPORT RI
02840-2200
US

IV. Provider business mailing address

75 NEWMAN AVE SUITE 100
RUMFORD RI
02916-3603
US

V. Phone/Fax

Practice location:
  • Phone: 401-499-7771
  • Fax:
Mailing address:
  • Phone: 401-453-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number10503
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT01902
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number10503
License Number StateRI

VIII. Authorized Official

Name: RAUL A MASING
Title or Position: OWNER
Credential: MD
Phone: 401-499-7771