1790279719 NPI number — EDYTA REIS RN

Table of content: EDYTA REIS RN (NPI 1790279719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790279719 NPI number — EDYTA REIS RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REIS
Provider First Name:
EDYTA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790279719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 ELLENFIELD ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-4513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-444-6779
Provider Business Mailing Address Fax Number:
401-444-6912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101-103 BACON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWTUCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-722-3560
Provider Business Practice Location Address Fax Number:
401-722-5280
Provider Enumeration Date:
06/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WC1500X , with the licence number:  RN54971 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1821078932 . This is a "GATEWAY" identifier . This identifiers is of the category "OTHER".




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