Healthcare Provider Details

I. General information

NPI: 1639090145
Provider Name (Legal Business Name): MASSAGE THERAPIST LONG ISLAND PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BROADWAY
MALVERNE NY
11565-1635
US

IV. Provider business mailing address

114 BROADWAY
MALVERNE NY
11565-1635
US

V. Phone/Fax

Practice location:
  • Phone: 516-887-8900
  • Fax: 516-200-0100
Mailing address:
  • Phone: 516-887-8900
  • Fax: 516-200-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA MILTCHEVA
Title or Position: MANAGER
Credential: LMT
Phone: 516-887-8900