Provider Demographics
NPI:1043718752
Name:BOTI DIET LLC
Entity Type:Organization
Organization Name:BOTI DIET LLC
Other - Org Name:BOTI DIET LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-595-2879
Mailing Address - Street 1:6 HOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 HOOD AVE
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:RI
Practice Address - Zip Code:02916-1504
Practice Address - Country:US
Practice Address - Phone:401-595-2879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center