Healthcare Provider Details

I. General information

NPI: 1154807717
Provider Name (Legal Business Name): OCEAN STATE PRIMARY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TOLL GATE RD STE 101B
WARWICK RI
02886-4447
US

IV. Provider business mailing address

2130 MENDON RD STE 3-333
CUMBERLAND RI
02864-3844
US

V. Phone/Fax

Practice location:
  • Phone: 401-921-5855
  • Fax:
Mailing address:
  • Phone: 401-353-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ZUBA
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 401-626-2748