Healthcare Provider Details

I. General information

NPI: 1417207028
Provider Name (Legal Business Name): LONG ISLAND CHIROPRACTIC & PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GILBERT AVE SUITE 201
SMITHTOWN NY
11787
US

IV. Provider business mailing address

20 GILBERT AVE SUITE 201
SMITHTOWN NY
11787
US

V. Phone/Fax

Practice location:
  • Phone: 631-724-1991
  • Fax: 631-724-1995
Mailing address:
  • Phone: 631-724-1991
  • Fax: 631-724-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. DONALD JOHN WALLACE
Title or Position: PRESIDENT
Credential: DC
Phone: 631-360-0170