Provider Demographics
NPI:1710325774
Name:PGREILLY INC
Entity Type:Organization
Organization Name:PGREILLY INC
Other - Org Name:ACTIVERX WESTBOROUGH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-329-1163
Mailing Address - Street 1:24 LYMAN ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-1484
Mailing Address - Country:US
Mailing Address - Phone:508-329-1163
Mailing Address - Fax:508-986-7026
Practice Address - Street 1:24 LYMAN ST
Practice Address - Street 2:SUITE 140
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1484
Practice Address - Country:US
Practice Address - Phone:508-329-1163
Practice Address - Fax:508-986-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0033180OtherMEDICARE PTAN