Provider Demographics
NPI:1275874760
Name:MYOFASCIAL PAIN TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:MYOFASCIAL PAIN TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:781-894-9430
Mailing Address - Street 1:203 ARLINGTON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2090
Mailing Address - Country:US
Mailing Address - Phone:781-894-9430
Mailing Address - Fax:
Practice Address - Street 1:203 ARLINGTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2090
Practice Address - Country:US
Practice Address - Phone:781-894-9430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN234770261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain