Provider Demographics
NPI:1770505273
Name:CHARLES STREET FAMILY CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:CHARLES STREET FAMILY CHIROPRACTIC, INC
Other - Org Name:CHARLES STREET FAMILY CHIROPRACTIC & PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CELESIA
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:617-720-1992
Mailing Address - Street 1:102 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4607
Mailing Address - Country:US
Mailing Address - Phone:617-720-1992
Mailing Address - Fax:617-248-9916
Practice Address - Street 1:102 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4607
Practice Address - Country:US
Practice Address - Phone:617-720-1992
Practice Address - Fax:617-248-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222111N00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY39316OtherBCBS GROUP NUMBER
641432OtherTUFTS GROUP NUMBER
4258513OtherAETNA
5190774OtherCIGNA GROUP NUMBER