Provider Demographics
NPI:1114117439
Name:SCLAVOS, KOSTAS (DC)
Entity Type:Individual
Prefix:
First Name:KOSTAS
Middle Name:
Last Name:SCLAVOS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 UDALL RD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-1853
Mailing Address - Country:US
Mailing Address - Phone:631-422-2225
Mailing Address - Fax:
Practice Address - Street 1:720 UDALL RD
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-1853
Practice Address - Country:US
Practice Address - Phone:631-422-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX63121OtherMEDICARE
U49818Medicare UPIN