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

Table of Contents

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

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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