Healthcare Provider Details

I. General information

NPI: 1649195421
Provider Name (Legal Business Name): KEVIN FERNANDES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W MAIN ST
NORTHBOROUGH MA
01532-2163
US

IV. Provider business mailing address

411 W MAIN ST
NORTHBOROUGH MA
01532-2163
US

V. Phone/Fax

Practice location:
  • Phone: 508-393-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number89758
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: