Basic Information
| Provider Information | |||||||||
| NPI: | 1144709114 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCCOLO | ||||||||
| FirstName: | JAKE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 RICHMOND SQ STE 200 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014334172 | ||||||||
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| Practice Location | |||||||||
| Address1: | 227 CENTERVILLE RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028864394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017267100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2018 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT03093 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.