Provider Demographics
NPI:1174564546
Name:RHODE ISLAND INTEGRATED MEDICINE
Entity type:Organization
Organization Name:RHODE ISLAND INTEGRATED MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:401-781-3374
Mailing Address - Street 1:521 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2346
Mailing Address - Country:US
Mailing Address - Phone:401-781-3374
Mailing Address - Fax:401-781-3376
Practice Address - Street 1:521 PARK AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2346
Practice Address - Country:US
Practice Address - Phone:401-781-3374
Practice Address - Fax:401-781-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI244DC111NN0400X
RIISW1224104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIT53637Medicare UPIN
RI007058069Medicare ID - Type Unspecified