Provider Demographics
NPI:1043842362
Name:FULL STRIDE SPINE & SPORT
Entity Type:Organization
Organization Name:FULL STRIDE SPINE & SPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PUNGELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-238-9651
Mailing Address - Street 1:150 KNICKERBOCKER AVE STE F
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-3163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 KNICKERBOCKER AVE STE F
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-3163
Practice Address - Country:US
Practice Address - Phone:845-238-9651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty