Basic Information
| Provider Information | |||||||||
| NPI: | 1639198765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTTARY | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 DEWEY RD | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021841204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816034389 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4458 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ROSLINDALE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021313440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173234377 | ||||||||
| FaxNumber: | 6173238077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2620 | MA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | Y37008 | 01 | MA | BCBSMA | OTHER | AA8919 | 01 | MA | HARVARD PILGRIM HEALTH | OTHER |