=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609073568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HYDE PARK CHOICE CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2007
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 BLUE HILL AVE
-----------------------------------------------------
City | MATTAPAN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02126-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-298-3200
-----------------------------------------------------
Fax | 617-298-3233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1551 BLUE HILL AVE
-----------------------------------------------------
City | MATTAPAN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02126-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-298-3200
-----------------------------------------------------
Fax | 617-298-3233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MR. EUGENE EMMANUEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-298-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 322
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------