Healthcare Provider Details

I. General information

NPI: 1427696574
Provider Name (Legal Business Name): JONATHAN D'ANGELO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7119 252ND ST
BELLEROSE NY
11426-2731
US

IV. Provider business mailing address

7119 252ND ST
BELLEROSE NY
11426-2731
US

V. Phone/Fax

Practice location:
  • Phone: 347-679-4899
  • Fax:
Mailing address:
  • Phone: 347-679-4899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number013386
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003163
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: