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General NPI Number Information
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NPI Number | 1376938654
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Entity Type | Organization
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Legal Business Name | VITA NOVA LLC
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Dates
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Enumeration Date | 04/02/2015
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Last Update Date | 04/02/2015
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Provider Practice Location Address
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Address Line | 66 PAVILION AVE
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City | PROVIDENCE
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State | RI
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Zip | 02905-1522
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Country | US
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Telephone | 401-780-2300
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Fax |
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Provider Business Mailing Address
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Address Line | 66 PAVILION AVE
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City | PROVIDENCE
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State | RI
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Zip | 02905-1522
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL & OPERATING OFFICER
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Name | MR. PETER MORRIS
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Credential |
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Telephone | 401-780-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | LIC 12-14-15588
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License Number State | UT
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