Provider Demographics
NPI:1710036033
Name:BENJAMIN GRACE
Entity Type:Organization
Organization Name:BENJAMIN GRACE
Other - Org Name:CHARLES RIVER CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-527-2702
Mailing Address - Street 1:717 WASHINGTON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1281
Mailing Address - Country:US
Mailing Address - Phone:617-527-2702
Mailing Address - Fax:
Practice Address - Street 1:717 WASHINGTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1281
Practice Address - Country:US
Practice Address - Phone:617-527-2702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACH2809111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45660Medicare ID - Type Unspecified