Provider Demographics
NPI:1093337420
Name:FORWARD SPINE & SPORT
Entity Type:Organization
Organization Name:FORWARD SPINE & SPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:MORAN
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:585-410-2081
Mailing Address - Street 1:285 HARVARD ST APT 301
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-2374
Mailing Address - Country:US
Mailing Address - Phone:585-410-2081
Mailing Address - Fax:
Practice Address - Street 1:285 HARVARD ST APT 301
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-2374
Practice Address - Country:US
Practice Address - Phone:585-410-2081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1609318013Medicaid