Healthcare Provider Details

I. General information

NPI: 1639124571
Provider Name (Legal Business Name): HEALTH 1 MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 MIDDLE COUNTRY RD SUITE 140
LAKE GROVE NY
11755-2124
US

IV. Provider business mailing address

2780 MIDDLE COUNTRY RD SUITE 140
LAKE GROVE NY
11755-2124
US

V. Phone/Fax

Practice location:
  • Phone: 631-580-1000
  • Fax: 631-580-0483
Mailing address:
  • Phone: 631-580-1000
  • Fax: 631-580-0483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: GARY DICANIO
Title or Position: OWNER
Credential: DO
Phone: 631-580-1000