Healthcare Provider Details

I. General information

NPI: 1992613566
Provider Name (Legal Business Name): JAXON ZAGORSKI TAMULAITES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WAMPANOAG TRL STE 1D
RIVERSIDE RI
02915-1511
US

IV. Provider business mailing address

51 EVERETT AVE
BRISTOL RI
02809-4723
US

V. Phone/Fax

Practice location:
  • Phone: 401-773-3700
  • Fax:
Mailing address:
  • Phone: 401-297-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: