Basic Information
| Provider Information | |||||||||
| NPI: | 1083293450 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVER FERN PRACTICE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4 RICHMOND SQ STE 200 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014334172 | ||||||||
| FaxNumber: | 4014330612 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 COMMONS CORNER WAY UNIT 12-A | ||||||||
| Address2: | |||||||||
| City: | SOUTH KINGSTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028792291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017267100 | ||||||||
| FaxNumber: | 4017229386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2021 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALBA | ||||||||
| AuthorizedOfficialFirstName: | KATELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HR COMPLIANCE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4014334172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SILVER FERN PRACTICE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
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.