Provider Demographics
NPI:1922478643
Name:SOUTH SHORE INJURY TREATMENT CENTER
Entity Type:Organization
Organization Name:SOUTH SHORE INJURY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-689-0440
Mailing Address - Street 1:25 SCHOOL ST
Mailing Address - Street 2:B2
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6607
Mailing Address - Country:US
Mailing Address - Phone:617-689-0440
Mailing Address - Fax:617-689-0420
Practice Address - Street 1:25 SCHOOL ST
Practice Address - Street 2:B2
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-6607
Practice Address - Country:US
Practice Address - Phone:617-689-0440
Practice Address - Fax:617-689-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80064208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty