Healthcare Provider Details

I. General information

NPI: 1609722503
Provider Name (Legal Business Name): SHALOM PHYSICAL THERAPY EVERETT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 BROADWAY
EVERETT MA
02149-3749
US

IV. Provider business mailing address

563 BROADWAY
EVERETT MA
02149-3749
US

V. Phone/Fax

Practice location:
  • Phone: 857-222-6510
  • Fax:
Mailing address:
  • Phone: 857-222-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIRZA LOPEZ
Title or Position: MANAGER/MEMBER
Credential:
Phone: 857-222-6510