1881669505 NPI number — MRS. LISA MARIE KOMNIK MSC, ATC

Table of content: MRS. LISA MARIE KOMNIK MSC, ATC (NPI 1881669505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881669505 NPI number — MRS. LISA MARIE KOMNIK MSC, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMNIK
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSC, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1881669505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 W ROE BLVD
Provider Second Line Business Mailing Address:
DANZI ATHLETIC CENTER
Provider Business Mailing Address City Name:
PATCHOGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11772-2325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-447-3330
Provider Business Mailing Address Fax Number:
631-447-3347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NICHOLLS ROAD SPORTS COMPLEX G33
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11794-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-632-7164
Provider Business Practice Location Address Fax Number:
631-632-7210
Provider Enumeration Date:
02/17/2006

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: 2255A2300X , with the licence number:  000038-1 , 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)





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