Provider Demographics
NPI:1417215690
Name:WEST SIDE WELLNESS, LLC
Entity Type:Organization
Organization Name:WEST SIDE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RITA
Authorized Official - Last Name:RAIMONDI
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:401-274-2225
Mailing Address - Street 1:376 WEST FOUNTAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PROVINCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-274-2225
Mailing Address - Fax:401-274-2228
Practice Address - Street 1:376 WEST FOUNTAIN STREET
Practice Address - Street 2:
Practice Address - City:PROVINCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-274-2225
Practice Address - Fax:401-274-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01476225700000X
RIMT01801225700000X
RIMT01765225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty