1083195895 NPI number — STEPHANIE LAUREN VANSCHAICK DPT

Table of content: STEPHANIE LAUREN VANSCHAICK DPT (NPI 1083195895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083195895 NPI number — STEPHANIE LAUREN VANSCHAICK DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANSCHAICK
Provider First Name:
STEPHANIE
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEREZ
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
LAUREN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083195895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISLIP
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11751-3620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-666-3951
Provider Business Mailing Address Fax Number:
631-666-3994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 MEDFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-1281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-758-1910
Provider Business Practice Location Address Fax Number:
631-758-1984
Provider Enumeration Date:
08/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  043431 , 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)





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