Provider Demographics
NPI:1720482193
Name:BLACKSTONE VALLEY FOOT AND ANKLE INC.
Entity type:Organization
Organization Name:BLACKSTONE VALLEY FOOT AND ANKLE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:DOMENICO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:401-725-5576
Mailing Address - Street 1:345 ARMISTICE BLVD
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-2429
Mailing Address - Country:US
Mailing Address - Phone:401-725-5576
Mailing Address - Fax:401-725-2640
Practice Address - Street 1:345 ARMISTICE BLVD
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-2429
Practice Address - Country:US
Practice Address - Phone:401-725-5576
Practice Address - Fax:401-725-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00327213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU400131218Medicare PIN
RI7369700001Medicare NSC