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General NPI Number Information
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NPI Number | 1174820120
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Entity Type | Organization
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Legal Business Name | PORT JEFFERSON CHIROPRACTIC OFFICE PC
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Dates
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Enumeration Date | 02/26/2011
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Last Update Date | 02/26/2011
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Provider Practice Location Address
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Address Line | 416 ROUTE 25A
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City | SETAUKET
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State | NY
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Zip | 11733-3841
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Country | US
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Telephone | 631-751-7700
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Fax | 631-751-7096
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Provider Business Mailing Address
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Address Line | 416 ROUTE 25A
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City | SETAUKET
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State | NY
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Zip | 11733-3841
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Country | US
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Telephone | 631-751-7700
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Fax | 631-751-7096
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Authorized Official
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Title or Position | SOLE OWNER OF CORPORATION
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Name | MICHAEL HORNEY
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Credential | DC
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Telephone | 631-751-7700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | X002824
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License Number State | NY
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