Basic Information
| Provider Information | |||||||||
| NPI: | 1487321469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYREN | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 454 E 3RD ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021271692 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 BEDFORD ST STE 5&6 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEWATER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023243187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082790033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2021 | ||||||||
| LastUpdateDate: | 09/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 25735 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.