Healthcare Provider Details

I. General information

NPI: 1790221232
Provider Name (Legal Business Name): LIFESPAN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 ALLENS AVE
PROVIDENCE RI
02905-5443
US

IV. Provider business mailing address

765 ALLENS AVE
PROVIDENCE RI
02905-5443
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283XC2000X
TaxonomyChildren's Rehabilitation Hospital
License NumberOT01595
License Number StateRI

VIII. Authorized Official

Name: CAITLYN MERCER
Title or Position: OTR/L
Credential:
Phone: 401-432-6800