Basic Information
| Provider Information | |||||||||
| NPI: | 1376593368 | ||||||||
| 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: | 4019464250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1180 BEACON ST | ||||||||
| Address2: | SUITE 6-C | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024463838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177305337 | ||||||||
| FaxNumber: | 6177305461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/20/2012 | ||||||||
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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 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y65633 | 01 | MA | BCBSMA GROUP # | OTHER |