Provider Demographics
NPI:1255962379
Name:SEAPORT SPINE PLLC
Entity type:Organization
Organization Name:SEAPORT SPINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-519-3607
Mailing Address - Street 1:11 BUNTON ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5704
Mailing Address - Country:US
Mailing Address - Phone:617-519-3607
Mailing Address - Fax:
Practice Address - Street 1:212 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-2089
Practice Address - Country:US
Practice Address - Phone:617-519-3607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty