Basic Information
| Provider Information | |||||||||
| NPI: | 1962576207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S. , P.T. | ||||||||
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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: | 160 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023301027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088661003 | ||||||||
| FaxNumber: | 5088667118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 5162 | MA | N | Other Service Providers | Specialist | 225100000X | 5162 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y65702 | 01 | MA | PROVIDER NUMBER | OTHER |