Healthcare Provider Details

I. General information

NPI: 1467980771
Provider Name (Legal Business Name): CONNETQUOT PT & CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 VETERANS HWY
RONKONKOMA NY
11779-7647
US

IV. Provider business mailing address

2103 DEER PARK AVE
DEER PARK NY
11729-1317
US

V. Phone/Fax

Practice location:
  • Phone: 631-738-9539
  • Fax: 631-738-8500
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 Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JACK TESORIERO
Title or Position: OWNER/CHIROPRACTOR
Credential:
Phone: 631-738-9539