Provider Demographics
NPI:1003118969
Name:IMAGINE CHIROPRACTIC HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:IMAGINE CHIROPRACTIC HEALTHCARE, PLLC
Other - Org Name:CHAMPION PERFORMANCE AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GUCCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-675-2758
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-0202
Mailing Address - Country:US
Mailing Address - Phone:631-675-2758
Mailing Address - Fax:631-675-2760
Practice Address - Street 1:5 S JERSEY AVE
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2045
Practice Address - Country:US
Practice Address - Phone:631-675-2758
Practice Address - Fax:631-675-2760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010407111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty