=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093097743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW VISION REHABILITATION CENTER LOWELL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2011
-----------------------------------------------------
Last Update Date | 09/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 173 PINE ST
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01851-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-656-1070
-----------------------------------------------------
Fax | 866-339-4550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1855
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-0015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-656-1070
-----------------------------------------------------
Fax | 866-339-4550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | OLEG DENISHENKO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-656-1070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------