Provider Demographics
NPI:1457522989
Name:THUNDERMIST HEALTH CENTER
Entity Type:Organization
Organization Name:THUNDERMIST HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CKARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUDELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-767-4100
Mailing Address - Street 1:171 SERVICE AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1015
Mailing Address - Country:US
Mailing Address - Phone:401-767-4100
Mailing Address - Fax:401-235-6833
Practice Address - Street 1:25 JOHN A CUMMINGS WAY
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3244
Practice Address - Country:US
Practice Address - Phone:401-767-4161
Practice Address - Fax:401-767-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIACF01569261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
RITH02580Medicaid