Healthcare Provider Details

I. General information

NPI: 1376593368
Provider Name (Legal Business Name): BACK ON TRACK, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 BEACON ST SUITE 6-C
BROOKLINE MA
02446-3838
US

IV. Provider business mailing address

721 RESERVOIR AVE
CRANSTON RI
02910-4430
US

V. Phone/Fax

Practice location:
  • Phone: 617-730-5337
  • Fax: 617-730-5461
Mailing address:
  • Phone: 401-946-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. HENRY SISUN
Title or Position: PRESIDENT/OWNER
Credential: PT
Phone: 617-730-5337