1376593368 NPI number — BACK ON TRACK, P.C.

Table of content: (NPI 1376593368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376593368 NPI number — BACK ON TRACK, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK ON TRACK, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376593368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 RESERVOIR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02910-4430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-946-4250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1180 BEACON ST
Provider Second Line Business Practice Location Address:
SUITE 6-C
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02446-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-730-5337
Provider Business Practice Location Address Fax Number:
617-730-5461
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SISUN
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
617-730-5337

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y65633 . This is a "BCBSMA GROUP #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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