Healthcare Provider Details

I. General information

NPI: 1083696579
Provider Name (Legal Business Name): MICHAEL JOSEPH STARE DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CUMMINGS CTR SUITE 121Q
BEVERLY MA
01915-6115
US

IV. Provider business mailing address

6 CORLISS RD
WINDHAM NH
03087-2388
US

V. Phone/Fax

Practice location:
  • Phone: 978-927-0907
  • Fax: 978-927-0537
Mailing address:
  • Phone: 603-918-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number15505
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: