Provider Demographics
NPI:1013106483
Name:SECOND WIND PHYSICAL THERAPY & SPORTS MEDICINE INC.
Entity Type:Organization
Organization Name:SECOND WIND PHYSICAL THERAPY & SPORTS MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDON
Authorized Official - Middle Name:
Authorized Official - Last Name:LACHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:617-429-2042
Mailing Address - Street 1:115 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2110
Mailing Address - Country:US
Mailing Address - Phone:617-569-2929
Mailing Address - Fax:617-569-2925
Practice Address - Street 1:115 PORTER ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2110
Practice Address - Country:US
Practice Address - Phone:617-569-2929
Practice Address - Fax:617-569-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0330299Medicaid