Provider Demographics
NPI:1033566328
Name:BOSTON BODY EVOLUTION LLC
Entity Type:Organization
Organization Name:BOSTON BODY EVOLUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-396-7899
Mailing Address - Street 1:1300 BOYLSTON STREET
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT
Mailing Address - State:MA
Mailing Address - Zip Code:02467
Mailing Address - Country:US
Mailing Address - Phone:617-396-7899
Mailing Address - Fax:212-253-4039
Practice Address - Street 1:1290 BOYLSTON STREET
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467
Practice Address - Country:US
Practice Address - Phone:617-396-7899
Practice Address - Fax:212-253-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA245841174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA245841OtherLICENSE