Healthcare Provider Details

I. General information

NPI: 1912363185
Provider Name (Legal Business Name): GARDEN CITY PT & CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E GATE BLVD
GARDEN CITY NY
11530-2124
US

IV. Provider business mailing address

2103 DEER PARK AVE
DEER PARK NY
11729-1317
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 Number030587
License Number StateNY

VIII. Authorized Official

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