Healthcare Provider Details

I. General information

NPI: 1003250762
Provider Name (Legal Business Name): JACKSON HEIGHTS MEDICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 SEAGIRT BLVD
FAR ROCKAWAY NY
11691-2803
US

IV. Provider business mailing address

7535 31ST AVE SUITE 200
EAST ELMHURST NY
11370-1857
US

V. Phone/Fax

Practice location:
  • Phone: 718-565-6880
  • Fax: 877-796-4457
Mailing address:
  • Phone: 718-565-6880
  • Fax: 718-565-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CARL A. NICHOLEAU
Title or Position: OWNER
Credential:
Phone: 718-344-5293