MEDICARE: BAYSHORE CHIROPRACTIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X009043	NY

General Provider Information

NPI Number	:	1255646360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSHORE CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	595 STEWART AVE
Second Line	:	SUITE 750
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-4787
Country	:	US
Telephone Number	:	516-307-1345
Fax Number	:

Provider Business Practice Location Address
First Line	:	1590 UNION BLVD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-7358
Country	:	US
Telephone Number	:	631-665-2421
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT SUPER
Credential	:	DC
Telephone Number	:	516-307-1345

Provider Enumeration Date	:	08/12/2010
Last Update Date	:	08/12/2010

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