=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962189456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND CHIROPRACTIC & NEXT STEP PHYSICAL THERAPY OF HICKSVILLE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2023
-----------------------------------------------------
Last Update Date | 08/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 W OLD COUNTRY RD
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-822-1900
-----------------------------------------------------
Fax | 516-681-3423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 W OLD COUNTRY RD
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-822-1900
-----------------------------------------------------
Fax | 516-681-3423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DR BRETT PASTUCH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 516-822-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------