Healthcare Provider Details

I. General information

NPI: 1871580282
Provider Name (Legal Business Name): JACK JAMES TESORIERO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
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 TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX004766
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: