Provider Demographics
NPI:1891840922
Name:SPINE & SPORTS INJURY CENTER, P.C.
Entity Type:Organization
Organization Name:SPINE & SPORTS INJURY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-877-7754
Mailing Address - Street 1:1 DALTON ST UNIT 3404
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3187
Mailing Address - Country:US
Mailing Address - Phone:617-877-7754
Mailing Address - Fax:617-936-4196
Practice Address - Street 1:209 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5109
Practice Address - Country:US
Practice Address - Phone:617-247-2300
Practice Address - Fax:617-936-4196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA966111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY49258OtherMEDICARE GROUP #