Healthcare Provider Details

I. General information

NPI: 1033554894
Provider Name (Legal Business Name): BACK BAY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 BOYLSTON ST # 3
BOSTON MA
02116-4824
US

IV. Provider business mailing address

665 BOYLSTON ST # 3
BOSTON MA
02116-4824
US

V. Phone/Fax

Practice location:
  • Phone: 724-554-2795
  • Fax: 857-350-3251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY RICHARD LATHAM
Title or Position: OWNER
Credential: DC
Phone: 724-554-2795