Provider Demographics
NPI:1639404635
Name:PROVIDENT PAIN AND WELLNESS CLINIC
Entity Type:Organization
Organization Name:PROVIDENT PAIN AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MASING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-499-7771
Mailing Address - Street 1:75 NEWMAN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-3603
Mailing Address - Country:US
Mailing Address - Phone:401-453-0666
Mailing Address - Fax:
Practice Address - Street 1:19 FRIENDSHIP ST
Practice Address - Street 2:SUITE 160
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2200
Practice Address - Country:US
Practice Address - Phone:401-499-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI10503207L00000X, 2081P2900X
RIPT01902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty