Healthcare Provider Details

I. General information

NPI: 1548408784
Provider Name (Legal Business Name): KEVORK AGOP KECHICHIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ARMISTICE BLVD
PAWTUCKET RI
02860-5354
US

IV. Provider business mailing address

59 OLD WILLIS RD
CUMBERLAND RI
02864-6624
US

V. Phone/Fax

Practice location:
  • Phone: 401-723-4336
  • Fax: 401-723-4336
Mailing address:
  • Phone: 401-723-4336
  • Fax: 401-723-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDAOM00032
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: