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General NPI Number Information
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NPI Number | 1417215690
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Entity Type | Organization
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Legal Business Name | WEST SIDE WELLNESS, LLC
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Dates
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Enumeration Date | 04/25/2012
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Last Update Date | 10/20/2017
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Provider Practice Location Address
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Address Line | 376 WEST FOUNTAIN STREET
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City | PROVINCE
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State | RI
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Zip | 02903
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Country | US
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Telephone | 401-274-2225
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Fax | 401-274-2228
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Provider Business Mailing Address
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Address Line | 376 WEST FOUNTAIN STREET
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City | PROVINCE
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State | RI
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Zip | 02903
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Country | US
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Telephone | 401-274-2225
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Fax | 401-274-2228
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER RITA RAIMONDI
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Credential | LMT
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Telephone | 401-274-2225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT01801
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT01765
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License Number State | RI
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Taxonomy #3
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT01476
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License Number State | RI
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