1255484168 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 1255484168 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:
1255484168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2011
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:
617-730-5337
Provider Business Mailing Address Fax Number:
617-730-5461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1269 BEACON ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02446-5248
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:
Provider Enumeration Date:
01/22/2007

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 , with the licence number:  38 , 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: OG0001 . This is a "BC LEGACY OT SERVICES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y65633 . This is a "BC LEGACY PT SERVICES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 605716 . This is a "HPHC LEGACY" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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