MEDICARE: BRONX CHIROPRACTIC SERVICES 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	:	1811202922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRONX CHIROPRACTIC SERVICES 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	:	1957 SOUTHERN BLVD
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10460-1419
Country	:	US
Telephone Number	:	347-590-7094
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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