Provider Demographics
NPI:1669038345
Name:FISH, ALLEN JEREMIAH
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:JEREMIAH
Last Name:FISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ASH ST
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02838-1520
Mailing Address - Country:US
Mailing Address - Phone:860-455-8411
Mailing Address - Fax:
Practice Address - Street 1:250 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2218
Practice Address - Country:US
Practice Address - Phone:860-455-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT02300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist