Healthcare Provider Details

I. General information

NPI: 1417127820
Provider Name (Legal Business Name): BROOKLYN CHIROPRACTIC SPINE & SPORTS INJURY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 LEXINGTON AVE SUITE 1903
NEW YORK NY
10022-6837
US

IV. Provider business mailing address

570 LEXINGTON AVE SUITE 1903
NEW YORK NY
10022-6837
US

V. Phone/Fax

Practice location:
  • Phone: 212-486-8616
  • Fax: 212-486-8621
Mailing address:
  • Phone: 212-486-8616
  • Fax: 212-486-8621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberX005160
License Number StateNY

VIII. Authorized Official

Name: DR. THOMAS J. BONACUSO JR.
Title or Position: PRESIDENT
Credential: D.C.; CCSP
Phone: 212-486-8616