Provider Demographics
NPI:1508986787
Name:HOLISTIC CENTER AT BRISTOL SQUARE PLLC
Entity Type:Organization
Organization Name:HOLISTIC CENTER AT BRISTOL SQUARE PLLC
Other - Org Name:BRISTOL SQUARE CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BETHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-660-2722
Mailing Address - Street 1:1426 MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1700
Mailing Address - Country:US
Mailing Address - Phone:508-660-2722
Mailing Address - Fax:508-660-2621
Practice Address - Street 1:1426 MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1700
Practice Address - Country:US
Practice Address - Phone:508-660-2722
Practice Address - Fax:508-660-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
MA262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT90164Medicare UPIN