Healthcare Provider Details

I. General information

NPI: 1568935120
Provider Name (Legal Business Name): VATRA SPINA AND SPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4454 AUSTIN BVLD.
ISLAND PARK NY
11558-1155
US

IV. Provider business mailing address

4454 AUSTIN BVLD.
ISLAND PARK NY
11558
US

V. Phone/Fax

Practice location:
  • Phone: 516-432-2100
  • Fax:
Mailing address:
  • Phone: 516-432-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY TODD
Title or Position: OWNER
Credential: DC
Phone: 516-432-2100