MEDICARE: MR. JUSTIN J BONACCI PT

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	225100000X	Physical Therapist	017345-1	NY

General Provider Information

NPI Number	:	1700865136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN J BONACCI PT

Provider Business Mailing Address
First Line	:	4 QUINCY ST
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-3420
Country	:	US
Telephone Number	:	631-467-4235
Fax Number	:	631-467-2655

Provider Business Practice Location Address
First Line	:	1636 MONTAUK HWY
Second Line	:	STE 4
City	:	MASTIC
State	:	NY
Zip	:	11950-3016
Country	:	US
Telephone Number	:	631-399-0007
Fax Number	:	631-399-2992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	10/31/2017

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