Healthcare Provider Details

I. General information

NPI: 1952402455
Provider Name (Legal Business Name): LEONARD NICHOLAS MARINO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1292 VICTORY BLVD
STATEN ISLAND NY
10301-3904
US

IV. Provider business mailing address

1292 VICTORY BLVD
STATEN ISLAND NY
10301-3904
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-9000
  • Fax: 718-816-0441
Mailing address:
  • Phone: 718-816-9000
  • Fax: 718-816-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberX007221-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: