| Name: | HAROLD J. WANEBO, MD, LLC |
| Jurisdiction: | Rhode Island |
| Entity type: | Domestic Limited Liability Company |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 30 Jan 2014 (11 years ago) |
| Date of Dissolution: | 14 Feb 2022 (3 years ago) |
| Date of Status Change: | 14 Feb 2022 (3 years ago) |
| Identification Number: | 000897822 |
| ZIP code: | 02809 |
| County: | Bristol County |
| Principal Address: | 116 POPPASQUASH ROAD, BRISTOL, RI, 02809, USA |
| Purpose: | TO OPERATE A MEDICAL OFFICE |
| NAICS: | 621111 - Offices of Physicians (except Mental Health Specialists) |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1740609981 | 2014-04-15 | 2015-03-26 | 1165 N MAIN ST, 2ND FLOOR, PROVIDENCE, RI, 029045740, US | 1165 N MAIN ST, 2ND FLOOR, PROVIDENCE, RI, 029045740, US | |||||||||||||||||||||||||
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| Phone | +1 401-529-2828 |
| Fax | 4019431958 |
Authorized person
| Name | DR. HAROLD J WANEBO |
| Role | OWNER |
| Phone | 4015292828 |
Taxonomy
| Taxonomy Code | 2086X0206X - Surgical Oncology Physician |
| License Number | MD07200 |
| State | RI |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 9006428 |
| State | RI |
| Name | Role | Address |
|---|---|---|
| STEPHEN D. ZUBIAGO, ESQ. | Agent | NIXON PEABODY LLP ONE CITIZENS PLAZA SUITE 500, PROVIDENCE, RI, 02903, USA |
| Name | Role | Address |
|---|---|---|
| HAROLD J. WANEBO MD | MANAGER | 116 POPPASQUASH ROAD BRISTOL, RI 02809 USA |
| Number | Name | File Date |
|---|---|---|
| 202210280720 | Revocation Certificate For Failure to File the Annual Report for the Year | 2022-02-14 |
| 202105991850 | Revocation Notice For Failure to File An Annual Report | 2021-12-03 |
| 202071890120 | Annual Report | 2020-10-28 |
| 201924447780 | Annual Report | 2019-10-15 |
| 201879580280 | Annual Report | 2018-10-16 |
| 201754914690 | Annual Report | 2017-12-11 |
| 201612043250 | Annual Report | 2016-11-14 |
| 201587929090 | Annual Report | 2015-11-16 |
| 201434568270 | Articles of Organization | 2014-01-30 |
Date of last update: 18 Oct 2024
Sources: Rhode Island Department of State
