Healthcare Provider Details

I. General information

NPI: 1891190229
Provider Name (Legal Business Name): TB12 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 PATRIOT PL
FOXBOROUGH MA
02035-5100
US

IV. Provider business mailing address

240 PATRIOT PL
FOXBOROUGH MA
02035-5100
US

V. Phone/Fax

Practice location:
  • Phone: 508-543-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number18781
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1795
License Number StateMA

VIII. Authorized Official

Name: MR. ALEJANDRO GUERRERO
Title or Position: OPERATING MANAGER
Credential:
Phone: 508-543-4900