Provider Demographics
NPI:1568978690
Name:LIFESTYLE MEDICINE OF RHODE ISLAND, LLC
Entity Type:Organization
Organization Name:LIFESTYLE MEDICINE OF RHODE ISLAND, LLC
Other - Org Name:RI WEIGHTLOSS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-228-6844
Mailing Address - Street 1:1524 ATWOOD AVE STE 336
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3228
Mailing Address - Country:US
Mailing Address - Phone:401-228-6844
Mailing Address - Fax:401-228-6855
Practice Address - Street 1:1524 ATWOOD AVE STE 336
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3228
Practice Address - Country:US
Practice Address - Phone:401-228-6844
Practice Address - Fax:401-228-6855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD04110207Q00000X, 207QB0002X, 2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty