Healthcare Provider Details

I. General information

NPI: 1043718752
Provider Name (Legal Business Name): BOTI DIET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2018
Last Update Date: 01/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HOOD AVE
RUMFORD RI
02916-1504
US

IV. Provider business mailing address

6 HOOD AVE
RUMFORD RI
02916-1504
US

V. Phone/Fax

Practice location:
  • Phone: 401-595-2879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AUDREY HALL
Title or Position: OWNER
Credential:
Phone: 401-595-2879