Healthcare Provider Details

I. General information

NPI: 1639716632
Provider Name (Legal Business Name): NICHOLAS POLI PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 BOYLSTON ST
BOSTON MA
02116-2848
US

IV. Provider business mailing address

4 AVALON DR UNIT 4417
QUINCY MA
02169-4246
US

V. Phone/Fax

Practice location:
  • Phone: 857-449-7525
  • Fax:
Mailing address:
  • Phone: 914-560-6340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24639
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: