MEDICARE: CHIROPRACTIC SPORT JOINT CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	X007427	NY

General Provider Information

NPI Number	:	1588949721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC SPORT JOINT CARE

Provider Business Mailing Address
First Line	:	1931 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3889
Country	:	US
Telephone Number	:	718-477-9300
Fax Number	:	718-477-9301

Provider Business Practice Location Address
First Line	:	1931 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3889
Country	:	US
Telephone Number	:	718-477-9300
Fax Number	:	718-477-9301

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARIO FUNICELLI
Credential	:	DC
Telephone Number	:	718-477-9300

Provider Enumeration Date	:	10/19/2011
Last Update Date	:	08/29/2014

Similar Medicare Providers

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Practice Location Address:

1931 RICHMOND AVE
STATEN ISLAND, NY
10314-3889

Practice Phone: 718-477-9300
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Practice Location Address:

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10314-3889

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Practice Fax: 718-477-9301

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Practice Location Address:

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STATEN ISLAND, NY
10314-3889

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Practice Location Address:

1931 RICHMOND AVE STE 203
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Practice Fax:

1194555763 — DREW CARABALLO NP
Practice Location Address:

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