Healthcare Provider Details

I. General information

NPI: 1215645742
Provider Name (Legal Business Name): EMMANUEL MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 DOUGLAS AVE STE 2
NORTH PROVIDENCE RI
02904-4057
US

IV. Provider business mailing address

10 DORRANCE ST STE 700
PROVIDENCE RI
02903-2014
US

V. Phone/Fax

Practice location:
  • Phone: 401-200-8242
  • Fax: 401-415-0418
Mailing address:
  • Phone: 401-200-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ADEBOLA ADELAIYE
Title or Position: OWNER
Credential: NP
Phone: 401-200-8242