Provider Demographics
NPI:1891190229
Name:TB12 LLC
Entity Type:Organization
Organization Name:TB12 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-543-4900
Mailing Address - Street 1:240 PATRIOT PL
Mailing Address - Street 2:
Mailing Address - City:FOXBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:02035-5100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 PATRIOT PL
Practice Address - Street 2:
Practice Address - City:FOXBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:02035-5100
Practice Address - Country:US
Practice Address - Phone:508-543-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18781225100000X
MA17952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty