| Name: | FAIRFAX ACNE & DERMATOLOGY SERVICES, P.C. |
| Jurisdiction: | Rhode Island |
| Entity type: | Foreign Corporation |
| Status: | Activ |
| Date of Organization in Rhode Island: | 21 Dec 2022 (2 years ago) |
| Identification Number: | 001750031 |
| ZIP code: | 02914 |
| County: | Providence County |
| Place of Formation: | MASSACHUSETTS |
| Principal Address: | 1275 WAMPANOAG TRAIL SUITE 6, EAST PROVIDENCE, RI, 02914, USA |
| Purpose: | TO ENGAGE IN THE BUSINESS OF PROVIDING DERMATOLOGIC CONSULTING AND MEDICAL SERVICES, AS A LICENSED NURSE PRACTITIONER TO INDIVIDUAL PATIENTS |
| NAICS: | 621111 - Offices of Physicians (except Mental Health Specialists) |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1245947332 | 2022-10-31 | 2022-10-31 | 1275 WAMPANOAG TRAIL, STE. 6, EAST PROVIDENCE, RI, 029151217, US | 1275 WAMPANOAG TRAIL, STE. 6, EAST PROVIDENCE, RI, 029151217, US | |||||||||||||
|
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| Phone | +1 508-404-4853 |
Authorized person
| Name | DIANA L FAIRFAX |
| Role | OWNER |
| Phone | 5084043853 |
Taxonomy
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| REGISTERED AGENT SOLUTIONS, INC. | Agent | 222 JEFFERSON BOULEVARD SUITE 200, WARWICK, RI, 02888, USA |
| Name | Role | Address |
|---|---|---|
| DIANA L. FAIRFAX | PRESIDENT | 103 GULF ROAD SOUTH DARTMOUTH, MA 02748 USA |
| Number | Name | File Date |
|---|---|---|
| 202453779740 | Annual Report | 2024-05-02 |
| 202338948580 | Annual Report | 2023-06-30 |
| 202338329820 | Revocation Notice For Failure to File An Annual Report | 2023-06-19 |
| 202225426490 | Application for Certificate of Authority | 2022-12-21 |
Date of last update: 29 Oct 2024
Sources: Rhode Island Department of State
