Provider Demographics
NPI:1013415678
Name:PROMISE INTEGRATIVE MEDICINE CLINIC RI
Entity Type:Organization
Organization Name:PROMISE INTEGRATIVE MEDICINE CLINIC RI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF ACUPUNCTURE ORIENTAL MEDI
Authorized Official - Prefix:
Authorized Official - First Name:HYUN SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:YEO
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:213-222-7481
Mailing Address - Street 1:535 ROOSEVELT AVE APT 611
Mailing Address - Street 2:
Mailing Address - City:CENTRAL FALLS
Mailing Address - State:RI
Mailing Address - Zip Code:02863-3204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2095 ELMWOOD AVE STE 1
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-2405
Practice Address - Country:US
Practice Address - Phone:401-787-1608
Practice Address - Fax:401-633-7610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROMISE INTEGRATIVE MEDICINE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDAOM0056171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty