=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902112709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTUMN DANCER RIDING ACADEMY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2010
-----------------------------------------------------
Last Update Date | 08/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 HARRINGTON RD
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01473-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-874-1015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 HARRINGTON RD
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01473-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-874-1015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANN CHERNOCH
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 978-874-1015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 8999
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------