MEDICARE: BOSTON BODY EVOLUTION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	245841	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	245841	OTHER	MA	LICENSE

General Provider Information

NPI Number	:	1033566328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOSTON BODY EVOLUTION LLC

Provider Business Mailing Address
First Line	:	1300 BOYLSTON STREET
Second Line	:
City	:	CHESTNUT
State	:	MA
Zip	:	02467
Country	:	US
Telephone Number	:	617-396-7899
Fax Number	:	212-253-4039

Provider Business Practice Location Address
First Line	:	1290 BOYLSTON STREET
Second Line	:
City	:	CHESTNUT HILL
State	:	MA
Zip	:	02467
Country	:	US
Telephone Number	:	617-396-7899
Fax Number	:	212-253-4039

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DR. MICHAEL NGUYEN
Credential	:	MD
Telephone Number	:	617-396-7899

Provider Enumeration Date	:	05/17/2016
Last Update Date	:	05/17/2016

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Directions to “BOSTON BODY EVOLUTION LLC ” Practice Location

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