Basic Information
| Provider Information | |||||||||
| NPI: | 1043979693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SILVER FERN PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 RICHMOND SQ STE 200 | ||||||||
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| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014334172 | ||||||||
| FaxNumber: | 4014330612 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 MAIN ST STE 122 | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028854437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012892999 | ||||||||
| FaxNumber: | 4012892950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2021 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | ALBA | ||||||||
| AuthorizedOfficialFirstName: | KATELYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4014334172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PERFORMANCE PHYSICAL THERAPY | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.