Healthcare Provider Details

I. General information

NPI: 1770505273
Provider Name (Legal Business Name): CHARLES STREET FAMILY CHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 CHARLES ST
BOSTON MA
02114-4607
US

IV. Provider business mailing address

102 CHARLES ST
BOSTON MA
02114-4607
US

V. Phone/Fax

Practice location:
  • Phone: 617-720-1992
  • Fax: 617-248-9916
Mailing address:
  • Phone: 617-720-1992
  • Fax: 617-248-9916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number222
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. TIANA CELESIA
Title or Position: OFFICE MANAGER
Credential: RD
Phone: 617-720-1992