Provider Demographics
NPI:1659025831
Name:RI WELLNESS MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:RI WELLNESS MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:EUCHARIA
Authorized Official - Middle Name:U
Authorized Official - Last Name:IBEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-525-8202
Mailing Address - Street 1:468 SMITHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-4266
Mailing Address - Country:US
Mailing Address - Phone:401-525-8202
Mailing Address - Fax:308-888-6638
Practice Address - Street 1:468 SMITHFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-4266
Practice Address - Country:US
Practice Address - Phone:401-525-8202
Practice Address - Fax:308-888-6636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-07
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1194326991Medicaid
RI1659025831Medicaid