Provider Demographics
NPI:1104822576
Name:SOUTH SHORE SPORTS & MUSCULAR
Entity Type:Organization
Organization Name:SOUTH SHORE SPORTS & MUSCULAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LALLY
Authorized Official - Last Name:NEWCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-331-9600
Mailing Address - Street 1:90 LIBBEY INDUSTRIAL PKWY
Mailing Address - Street 2:STE 103
Mailing Address - City:EAST WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3129
Mailing Address - Country:US
Mailing Address - Phone:781-331-9600
Mailing Address - Fax:781-335-1556
Practice Address - Street 1:90 LIBBEY INDUSTRIAL PKWY
Practice Address - Street 2:STE 103
Practice Address - City:EAST WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3129
Practice Address - Country:US
Practice Address - Phone:781-331-9600
Practice Address - Fax:781-335-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty