MEDICARE: LAKE CHIROPRACTIC, PLLC.

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	111N00000X	Chiropractor	X2929	NY

General Provider Information

NPI Number	:	1972803104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE CHIROPRACTIC, PLLC.

Provider Business Mailing Address
First Line	:	201 PORTION RD
Second Line	:	SUITE A
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	631-981-1333
Fax Number	:	631-981-6766

Provider Business Practice Location Address
First Line	:	201 PORTION RD
Second Line	:	SUITE A
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	631-981-1333
Fax Number	:	631-981-6766

Authorized Official
Title or Position	:	CHIROPRACTOR/ PRESIDENT
Name	:	DR. RONALD ROBERT BERNARDINI
Credential	:	DC
Telephone Number	:	631-981-1333

Provider Enumeration Date	:	10/21/2010
Last Update Date	:	10/21/2010

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