Basic Information
| Provider Information | |||||||||
| NPI: | 1861521510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | R.I. COLORECTAL CLINIC 1, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 334 EAST AVENUE | ||||||||
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| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017254888 | ||||||||
| FaxNumber: | 4017253336 | ||||||||
| Practice Location | |||||||||
| Address1: | 334 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028603821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017254888 | ||||||||
| FaxNumber: | 4017253336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | SCHECHTER | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4017254888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208C00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.