Provider Demographics
NPI:1649673799
Name:STORTI, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:STORTI
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 1:28 COLUMBIA STREET
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879
Mailing Address - Country:US
Mailing Address - Phone:401-792-4949
Mailing Address - Fax:
Practice Address - Street 1:28 COLUMBIA STREET
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879
Practice Address - Country:US
Practice Address - Phone:401-792-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIADC00037261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care