Healthcare Provider Details

I. General information

NPI: 1962499467
Provider Name (Legal Business Name): SOUTH SHORE CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HORSEBLOCK RD
FARMINGVILLE NY
11738-1240
US

IV. Provider business mailing address

700 HORSEBLOCK RD
FARMINGVILLE NY
11738-1240
US

V. Phone/Fax

Practice location:
  • Phone: 631-732-1386
  • Fax: 631-732-1544
Mailing address:
  • Phone: 631-732-1386
  • Fax: 631-732-1544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX009193
License Number StateNY

VIII. Authorized Official

Name: MR. MICHAEL J CAMPO
Title or Position: CHIROPRACTOR OWNER
Credential: DC
Phone: 631-732-1386