Healthcare Provider Details

I. General information

NPI: 1902204050
Provider Name (Legal Business Name): LIFE LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MAIN ST
NORTH KINGSTOWN RI
02852-5112
US

IV. Provider business mailing address

30 W MAIN ST
NORTH KINGSTOWN RI
02852-5112
US

V. Phone/Fax

Practice location:
  • Phone: 401-295-5269
  • Fax:
Mailing address:
  • Phone: 401-295-5269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberRN48162
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberRN32761
License Number StateRI

VIII. Authorized Official

Name: MS. LORI E DELFOSSE
Title or Position: HEALTH DIRECTOR
Credential: RN
Phone: 401-932-9342