| Name: | Provident Pain and Wellness Clinic, LLC |
| Jurisdiction: | Rhode Island |
| Entity type: | Domestic Limited Liability Company |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 03 Apr 2009 (16 years ago) |
| Date of Dissolution: | 27 Jun 2017 (8 years ago) |
| Date of Status Change: | 27 Jun 2017 (8 years ago) |
| Identification Number: | 000505849 |
| ZIP code: | 02874 |
| County: | Washington County |
| Principal Address: | 77 HAGGERTY HILL ROAD, SAUNDERSTOWN, RI, 02874, USA |
| Purpose: | TO PROVIDE PAIN MANAGEMENT HEALTH CARE SERVICES |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1639404635 | 2009-10-08 | 2011-03-28 | 75 NEWMAN AVE, SUITE 100, RUMFORD, RI, 029163603, US | 19 FRIENDSHIP ST, SUITE 160, NEWPORT, RI, 028402200, US | |||||||||||||||||||||||||||||||||||
|
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| Phone | +1 401-453-0666 |
| Phone | +1 401-499-7771 |
Authorized person
| Name | RAUL A MASING |
| Role | OWNER |
| Phone | 4014997771 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| License Number | 10503 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2081P2900X - Pain Medicine (Physical Medicine & Rehabilitation) Physician |
| License Number | 10503 |
| State | RI |
| Is Primary | Yes |
| Taxonomy Code | 225100000X - Physical Therapist |
| License Number | PT01902 |
| State | RI |
| Is Primary | No |
| Name | Role | Address |
|---|---|---|
| GEORGE M. CAPPELLO, ESQ. | Agent | 942 PARK AVENUE, CRANSTON, RI, 02910, USA |
| Number | Name | File Date |
|---|---|---|
| 201746301950 | Revocation Certificate For Failure to File the Annual Report for the Year | 2017-06-27 |
| 201739787150 | Revocation Notice For Failure to File An Annual Report | 2017-04-06 |
| 201586568920 | Annual Report | 2015-10-29 |
| 201449282420 | Annual Report | 2014-10-31 |
| 201328671150 | Annual Report | 2013-09-23 |
| 201203840260 | Annual Report | 2012-11-08 |
| 201184141110 | Annual Report | 2011-10-14 |
| 201071594940 | Annual Report | 2010-11-01 |
| 200944819430 | Articles of Organization | 2009-04-03 |
Date of last update: 14 Oct 2024
Sources: Rhode Island Department of State
