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Wickford Family Practice LLC

Company Details

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

National Provider Identifier

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

Contacts

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

Agent

Name Role Address
MAXWELL HOGUE Agent 619 BOSTON NECK ROAD, NORTH KINGSTOWN, RI, 02852, USA

Filings

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