=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386865855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C O R E PHYSICAL THERAPY CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 04/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 388 PLEASANT ST SUITE 305
-----------------------------------------------------
City | MALDEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02148-8143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-388-0012
-----------------------------------------------------
Fax | 781-388-3312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 388 PLEASANT ST SUITE 305
-----------------------------------------------------
City | MALDEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02148-8143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-388-0012
-----------------------------------------------------
Fax | 781-388-3312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELIZABETH JEAN CANONI
-----------------------------------------------------
Credential | PT,DPT,MS
-----------------------------------------------------
Telephone | 781-388-0012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 11243
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------