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General NPI Number Information
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NPI Number | 1669038345
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Entity Type | Individual
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Provider Name | ALLEN JEREMIAH FISH
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Gender | Male
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Dates
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Enumeration Date | 05/17/2019
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Last Update Date | 05/17/2019
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Provider Practice Location Address
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Address Line | 250 WAMPANOAG TRL
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City | RIVERSIDE
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State | RI
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Zip | 02915-2218
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Country | US
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Telephone | 860-455-8411
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Fax |
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Provider Business Mailing Address
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Address Line | 38 ASH ST
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City | MANVILLE
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State | RI
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Zip | 02838-1520
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Country | US
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Telephone | 860-455-8411
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | MT02300
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License Number State | RI
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