Name: | Wickford Family Practice LLC |
Jurisdiction: | Rhode Island |
Entity type: | Domestic Limited Liability Company |
Status: | Activ |
Date of Organization in Rhode Island: | 29 Nov 2022 (2 years ago) |
Identification Number: | 001749189 |
ZIP code: | 02852 |
County: | Washington County |
Principal Address: | 619 BOSTON NECK ROAD, NORTH KINGSTOWN, RI, 02852, USA |
Mailing Address: | 320 PHILLIPS STREETS SUITE 102, NORTH KINGSTOWN, RI, 02852, USA |
Purpose: | SOLO PRACTICE PRIMARY CARE OFFICE RAN BY A NURSE PRACTITIONER. |
NAICS: | 621399 - Offices of All Other Miscellaneous Health Practitioners |
NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1710698667 | 2022-12-12 | 2023-02-01 | 619 BOSTON NECK RD, NORTH KINGSTOWN, RI, 028526235, US | 320 PHILLIPS ST STE 102, NORTH KINGSTOWN, RI, 028525149, US | |||||||||||||||||||||||||||||
|
Phone | +1 603-667-6765 |
Authorized person
Name | MAXWELL HOGUE |
Role | OWNER |
Phone | 6036676765 |
Taxonomy
Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
Is Primary | No |
Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
Is Primary | Yes |
Other Provider Identifiers
Issuer | MEDICAID |
Number | 1235789231 |
State | RI |
Issuer | STATE NP LICENSE |
Number | APRN02399 |
State | RI |
Name | Role | Address |
---|---|---|
MAXWELL HOGUE | Agent | 619 BOSTON NECK ROAD, NORTH KINGSTOWN, RI, 02852, USA |
Number | Name | File Date |
---|---|---|
202452088140 | Annual Report | 2024-04-23 |
202333047170 | Annual Report | 2023-04-17 |
202224923170 | Articles of Organization | 2022-11-29 |
Date of last update: 29 Oct 2024
Sources: Rhode Island Department of State