MEDICARE: CLOVER 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

General Provider Information

NPI Number	:	1801583547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLOVER CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	10 BOND ST # 490
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11021-2454
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 GLENWOOD ST
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11021-4010
Country	:	US
Telephone Number	:	516-218-0011
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	STEVEN WALLACH
Credential	:
Telephone Number	:	516-218-0011

Provider Enumeration Date	:	04/21/2023
Last Update Date	:	10/05/2023

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