Provider Demographics
NPI:1982743431
Name:RIVER STREET SPINE CLINIC PC
Entity Type:Organization
Organization Name:RIVER STREET SPINE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WARNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-298-1776
Mailing Address - Street 1:500 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2211
Mailing Address - Country:US
Mailing Address - Phone:617-298-1776
Mailing Address - Fax:617-298-7366
Practice Address - Street 1:500 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2211
Practice Address - Country:US
Practice Address - Phone:617-298-1776
Practice Address - Fax:617-298-7366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty