=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508306333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAD TO TOE CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2017
-----------------------------------------------------
Last Update Date | 02/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 NESCONSET HIGHWAY BUILDING 9B
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-0049
-----------------------------------------------------
Fax | 631-689-0071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 NESCONSET HIGHWAY BUILDING 9B
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-0049
-----------------------------------------------------
Fax | 631-689-0071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SUSAN TARA MACKEY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 631-689-0049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X007538-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------