1205837036 NPI number — MR. JOHN WAYNE INACIO P.T., A.T.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 1205837036 NPI number — MR. JOHN WAYNE INACIO P.T., A.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INACIO
Provider First Name:
JOHN
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T., A.T.C.
Provider Gender Code:
M

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:
1205837036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 LIBERTY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NATICK
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01760-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-647-2299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
NATICK
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01760-1131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-650-1856
Provider Business Practice Location Address Fax Number:
508-653-9563
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4097 , 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: Y65359 . This is a "MASSACHUSETTS BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 469186 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0370797 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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