=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033976147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND CARE CHIROPRACTIC OF SUFFOLK PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 W SUFFOLK AVE UNIT G
-----------------------------------------------------
City | CENTRAL ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11722-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-388-1188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 W SUFFOLK AVE UNIT G
-----------------------------------------------------
City | CENTRAL ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11722-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-993-5400
-----------------------------------------------------
Fax | 631-203-4468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MS. ROBERTA PEETS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 631-993-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------