1215999883 NPI number — LAWRENCE J FITZPATRICK LATC, PTA

Table of content: LAWRENCE J FITZPATRICK LATC, PTA (NPI 1215999883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215999883 NPI number — LAWRENCE J FITZPATRICK LATC, PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZPATRICK
Provider First Name:
LAWRENCE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LATC, PTA
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:
1215999883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 CENTRE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02186-3308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-696-1868
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 CENTRE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02186-3338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-898-2248
Provider Business Practice Location Address Fax Number:
617-898-1716
Provider Enumeration Date:
04/06/2006

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: 225200000X , with the licence number:  2004 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2255A2300X , with the licence number: 72 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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