Provider Demographics
NPI:1073634374
Name:CENTERVILLE PODIATRY LLC
Entity Type:Organization
Organization Name:CENTERVILLE PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CABRAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-738-9200
Mailing Address - Street 1:469 CENTERVILLE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4354
Mailing Address - Country:US
Mailing Address - Phone:401-738-9200
Mailing Address - Fax:401-738-9400
Practice Address - Street 1:469 CENTERVILLE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4354
Practice Address - Country:US
Practice Address - Phone:401-738-9200
Practice Address - Fax:401-738-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00277213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1246080001Medicare NSC