Provider Demographics
NPI:1447609938
Name:PHYSICAL THERAPY OF MATTAPAN SQUARE, LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY OF MATTAPAN SQUARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONROE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-784-3166
Mailing Address - Street 1:1596 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2121
Mailing Address - Country:US
Mailing Address - Phone:617-296-6800
Mailing Address - Fax:617-296-6810
Practice Address - Street 1:1596 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2121
Practice Address - Country:US
Practice Address - Phone:617-296-6800
Practice Address - Fax:617-296-6810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy