Provider Demographics
NPI:1649410507
Name:BACK AND BALANCE REHABILITATION CENTER
Entity Type:Organization
Organization Name:BACK AND BALANCE REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VYACHESLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:DENISHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-424-4749
Mailing Address - Street 1:665 BEACON ST
Mailing Address - Street 2:400
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3202
Mailing Address - Country:US
Mailing Address - Phone:617-424-4760
Mailing Address - Fax:
Practice Address - Street 1:665 BEACON ST
Practice Address - Street 2:400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3202
Practice Address - Country:US
Practice Address - Phone:617-424-4760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty