1891838538 NPI number — CHIROPRACTIC OF STONY BROOK PLLC

Table of content: (NPI 1891838538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891838538 NPI number — CHIROPRACTIC OF STONY BROOK PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC OF STONY BROOK PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891838538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1041 ROUTE 112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT JEFFERSON STATION
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11776-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-828-4545
Provider Business Mailing Address Fax Number:
631-642-1070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1041 ROUT 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT JEFFERSON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-828-4545
Provider Business Practice Location Address Fax Number:
631-642-1070
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BONASERA
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
631-828-4545

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: X005301-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01738361 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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