Healthcare Provider Details

I. General information

NPI: 1427920164
Provider Name (Legal Business Name): KENNETH JOHN KOPCZYNSKI JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 CARLETON AVE
CENTRAL ISLIP NY
11722-4172
US

IV. Provider business mailing address

38 ORCHARD ST
HAUPPAUGE NY
11788-4920
US

V. Phone/Fax

Practice location:
  • Phone: 631-650-2510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number774966-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: