Healthcare Provider Details

I. General information

NPI: 1568667848
Provider Name (Legal Business Name): WELLNORTH MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 MINERAL SPRING AVE 2
NORTH PROVIDENCE RI
02904-4025
US

IV. Provider business mailing address

1630 MINERAL SPRING AVE 2
NORTH PROVIDENCE RI
02904-4043
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-1010
  • Fax:
Mailing address:
  • Phone: 401-438-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAVID CALCATTI
Title or Position: DIRECTOR
Credential: MD
Phone: 401-438-1010