Healthcare Provider Details

I. General information

NPI: 1326463548
Provider Name (Legal Business Name): PROSPECT CHARTERCARE RWMC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax: 401-456-2029
Mailing address:
  • Phone: 401-456-2000
  • Fax: 401-456-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
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