Healthcare Provider Details

I. General information

NPI: 1992685358
Provider Name (Legal Business Name): CENTRO DE INNOVACION MUJER LATINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BROAD ST
PROVIDENCE RI
02907-1463
US

IV. Provider business mailing address

2597 HARTFORD AVE
JOHNSTON RI
02919-1620
US

V. Phone/Fax

Practice location:
  • Phone: 401-390-6816
  • Fax:
Mailing address:
  • Phone: 401-390-6816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EVYLEGNA MARIE RODRIGUEZ
Title or Position: DIRECTORA EJECUTIVA
Credential:
Phone: 401-390-6816