Healthcare Provider Details

I. General information

NPI: 1730361932
Provider Name (Legal Business Name): THOMAS LAWRENCE HALTON DOCTOR OF SCIENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 QUEENSBERRY ST APT 19
BOSTON MA
02215-5246
US

IV. Provider business mailing address

36 QUEENSBERRY ST APT 19
BOSTON MA
02215-5246
US

V. Phone/Fax

Practice location:
  • Phone: 617-536-8896
  • Fax:
Mailing address:
  • Phone: 617-536-8896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number2548
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: