Healthcare Provider Details

I. General information

NPI: 1245142231
Provider Name (Legal Business Name): GENE THERIAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ERDMAN WAY
LEOMINSTER MA
01453-1804
US

IV. Provider business mailing address

100 ERDMAN WAY
LEOMINSTER MA
01453-1804
US

V. Phone/Fax

Practice location:
  • Phone: 978-340-1772
  • Fax:
Mailing address:
  • Phone: 978-340-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: