Healthcare Provider Details

I. General information

NPI: 1487205324
Provider Name (Legal Business Name): FOREDEFI ATHLETIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MESSENGER ST
PLAINVILLE MA
02762
US

IV. Provider business mailing address

44 VINCENT RD
ATTLEBORO MA
02703
US

V. Phone/Fax

Practice location:
  • Phone: 774-643-6270
  • Fax:
Mailing address:
  • Phone: 774-306-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TYLER MCCARTHY
Title or Position: OWNER
Credential: DPT
Phone: 774-306-6141