Healthcare Provider Details

I. General information

NPI: 1508251612
Provider Name (Legal Business Name): DP PT & CHIROPRACTIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

IV. Provider business mailing address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

V. Phone/Fax

Practice location:
  • Phone: 631-242-4500
  • Fax: 631-242-0885
Mailing address:
  • Phone: 631-242-4500
  • Fax: 631-242-0885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number004766
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004142
License Number StateNY

VIII. Authorized Official

Name: DR. JACK J TESORIERO
Title or Position: MANAGING MEMBER
Credential: DC
Phone: 631-242-4500