Provider Demographics
NPI:1104639731
Name:
Entity type:Organization
Organization Name:
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:ENID
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:781-916-8825
Mailing Address - Street 1:40 CRESCENT ST STE 104
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-4313
Mailing Address - Country:US
Mailing Address - Phone:781-916-8825
Mailing Address - Fax:781-701-3570
Practice Address - Street 1:40 CRESCENT ST STE 104
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-4313
Practice Address - Country:US
Practice Address - Phone:781-916-8825
Practice Address - Fax:781-701-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-28
Last Update Date:2025-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy