Provider Demographics
NPI:1215649827
Name:WILD TAINO LLC
Entity type:Organization
Organization Name:WILD TAINO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBUCCIA
Authorized Official - Suffix:
Authorized Official - Credentials:CPD
Authorized Official - Phone:401-290-8076
Mailing Address - Street 1:1578 MAIN ST # A
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-4055
Mailing Address - Country:US
Mailing Address - Phone:401-290-8076
Mailing Address - Fax:
Practice Address - Street 1:1578 MAIN ST # A
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-4055
Practice Address - Country:US
Practice Address - Phone:401-290-8076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty