Healthcare Provider Details

I. General information

NPI: 1861521510
Provider Name (Legal Business Name): R.I. COLORECTAL CLINIC 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 EAST AVE
PAWTUCKET RI
02860-3821
US

IV. Provider business mailing address

334 EAST AVENUE
PAWTUCKET RI
02860
US

V. Phone/Fax

Practice location:
  • Phone: 401-725-4888
  • Fax: 401-725-3336
Mailing address:
  • Phone: 401-725-4888
  • Fax: 401-725-3336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NAOMI SCHECHTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 401-725-4888