Basic Information
| Provider Information | |||||||||
| NPI: | 1255484168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BACK ON TRACK, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 RESERVOIR AVE | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177305337 | ||||||||
| FaxNumber: | 6177305461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1269 BEACON ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024465248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177305337 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | SISUN | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6177305337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 38 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OG0001 | 01 | MA | BC LEGACY OT SERVICES | OTHER | Y65633 | 01 | MA | BC LEGACY PT SERVICES | OTHER | 605716 | 01 | MA | HPHC LEGACY | OTHER |