Healthcare Provider Details

I. General information

NPI: 1457807844
Provider Name (Legal Business Name): SPINE CENTER NORTH SHORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 BARTLETT RD
WINTHROP MA
02152-2913
US

IV. Provider business mailing address

6 BARTLETT RD
WINTHROP MA
02152-2913
US

V. Phone/Fax

Practice location:
  • Phone: 617-846-3502
  • Fax: 617-453-3411
Mailing address:
  • Phone: 617-846-3502
  • Fax: 617-453-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number655
License Number StateMA

VIII. Authorized Official

Name: DR. BRENDAN P. CORCORAN
Title or Position: OWNER
Credential: D.C.
Phone: 617-846-3502