Healthcare Provider Details

I. General information

NPI: 1033175823
Provider Name (Legal Business Name): RAYMOND NICINI PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HIGH ST
WAKEFIELD RI
02879-3103
US

IV. Provider business mailing address

1 HIGH ST
WAKEFIELD RI
02879-3103
US

V. Phone/Fax

Practice location:
  • Phone: 401-783-8077
  • Fax: 401-789-6029
Mailing address:
  • Phone: 401-783-8077
  • Fax: 401-789-6029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number00552
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: