Healthcare Provider Details

I. General information

NPI: 1053818369
Provider Name (Legal Business Name): ENVISION WELLNESS CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 LAKELAND AVE SUITE 9
BOHEMIA NY
11716
US

IV. Provider business mailing address

1461 LAKELAND AVE SUITE 9
BOHEMIA NY
11716
US

V. Phone/Fax

Practice location:
  • Phone: 631-467-8224
  • Fax: 631-585-7575
Mailing address:
  • Phone: 631-467-8224
  • Fax: 631-585-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberX003397-1
License Number StateNY

VIII. Authorized Official

Name: DR. FREDERICK TINARI
Title or Position: PRES./OWNER
Credential: DC
Phone: 631-467-8224