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NPI Code Detail

MEDICARE: PATCHOGUE-MEDFORD PT & CHIROPRACTIC PLLC

MEDICARE: PATCHOGUE-MEDFORD PT & CHIROPRACTIC PLLC
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
1111N00000XChiropractor004766NY
2225100000XPhysical Therapist025310NY

General Provider Information

NPI Number : 1255703807
Entity Type Code : Organization
Provider Name (Legal Business Name) : PATCHOGUE-MEDFORD PT & CHIROPRACTIC PLLC
Provider Business Mailing Address
First Line : 2103 DEER PARK AVE
Second Line :
City : DEER PARK
State : NY
Zip : 11729-1317
Country : US
Telephone Number : 631-242-4500
Fax Number : 631-242-0885
Provider Business Practice Location Address
First Line : 105 MEDFORD AVE
Second Line :
City : PATCHOGUE
State : NY
Zip : 11772-1223
Country : US
Telephone Number : 631-617-5040
Fax Number : 631-617-5559
Authorized Official
Title or Position : MANAGING MEMBER
Name : DR. JACK TESORIERO
Credential : DC
Telephone Number : 631-617-5040
Provider Enumeration Date : 10/22/2015
Last Update Date : 01/06/2016

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Directions to “PATCHOGUE-MEDFORD PT & CHIROPRACTIC PLLC ” Practice Location

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