Healthcare Provider Details

I. General information

NPI: 1295309953
Provider Name (Legal Business Name): CORE CHIROPRACTIC AND PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 MAIN ST STE 207
MILLIS MA
02054-1555
US

IV. Provider business mailing address

969 MAIN ST STE 207
MILLIS MA
02054-1555
US

V. Phone/Fax

Practice location:
  • Phone: 508-918-2185
  • Fax: 508-974-4467
Mailing address:
  • Phone: 508-918-2185
  • Fax: 508-974-4467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KELLY CHRISTINE CORNELL
Title or Position: OWNER
Credential: DC
Phone: 508-918-2185