Healthcare Provider Details

I. General information

NPI: 1578988572
Provider Name (Legal Business Name): PROSPECT CHARTERCARE SJHSRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

IV. Provider business mailing address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-3000
  • Fax: 401-456-3028
Mailing address:
  • Phone: 401-456-3000
  • Fax: 401-456-3028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT JON ELDERS
Title or Position: SECRETARY
Credential:
Phone: 714-788-1249