| Prairie Ave | |
|
355 Prairie Ave Providence RI 02905-5010 | |
| (401) 444-0570 | |
| (401) 444-0427 |
| Full Name | Prairie Ave |
|---|---|
| Speciality | Clinic/Center |
| Location | 355 Prairie Ave, Providence, Rhode Island |
| Authorized Official Name and Position | Kevin Cabral (CFO) |
| Authorized Official Contact | 4014440400 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Prairie Ave 375 Allens Ave Providence RI 02905-5010 Ph: (401) 444-0400 | Prairie Ave 355 Prairie Ave Providence RI 02905-5010 Ph: (401) 444-0570 |
| NPI Number | 1417959867 |
|---|---|
| Provider Enumeration Date | 08/15/2005 |
| Last Update Date | 12/05/2024 |
| Certification Date | 12/05/2024 |
| Medicare PECOS PAC ID | 9335050962 |
|---|---|
| Medicare Enrollment ID | O20030812000060 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417959867 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | () | Primary |
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