Healthcare Provider Details

I. General information

NPI: 1104957620
Provider Name (Legal Business Name): RUSSELL D. FIORE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BROWN UNIVERSITY 235 HOPE ST
PROVIDENCE RI
02912-0001
US

IV. Provider business mailing address

6 RED CHIMNEY DR
LINCOLN RI
02865-4610
US

V. Phone/Fax

Practice location:
  • Phone: 401-863-3851
  • Fax: 401-863-1156
Mailing address:
  • Phone: 401-723-1055
  • Fax: 401-863-1156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT00014
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: