Provider Demographics
NPI:1255484168
Name:BACK ON TRACK, P.C.
Entity Type:Organization
Organization Name:BACK ON TRACK, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SISUN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:617-730-5337
Mailing Address - Street 1:721 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4430
Mailing Address - Country:US
Mailing Address - Phone:617-730-5337
Mailing Address - Fax:617-730-5461
Practice Address - Street 1:1269 BEACON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5248
Practice Address - Country:US
Practice Address - Phone:617-730-5337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOG0001OtherBC LEGACY OT SERVICES
MAY65633OtherBC LEGACY PT SERVICES
MA605716OtherHPHC LEGACY
MA4939400001Medicare NSC
MA605716OtherHPHC LEGACY
MAPT0067Medicare PIN