Provider Demographics
NPI:1720261399
Name:EAST BOSTON CHIROPRACTIC AND REHABILITATION CLINIC, INC.
Entity Type:Organization
Organization Name:EAST BOSTON CHIROPRACTIC AND REHABILITATION CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-561-5151
Mailing Address - Street 1:125 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1954
Mailing Address - Country:US
Mailing Address - Phone:617-561-5151
Mailing Address - Fax:617-561-4039
Practice Address - Street 1:125 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1954
Practice Address - Country:US
Practice Address - Phone:617-561-5151
Practice Address - Fax:617-561-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2565111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA483219Medicare UPIN