Basic Information
| Provider Information | |||||||||
| NPI: | 1235244021 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILTON CHIROPRACTIC AND REHABILITATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAY STATE PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 WILLARD ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021691274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177700022 | ||||||||
| FaxNumber: | 6174711114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINDWER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7819613370 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC, PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 1542 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 723097 | 01 | MA | TUFTS HEALTH PLAN | OTHER | Y39093 | 01 | MA | BCBSMA | OTHER |