Provider Demographics
NPI:1174820120
Name:PORT JEFFERSON CHIROPRACTIC OFFICE PC
Entity Type:Organization
Organization Name:PORT JEFFERSON CHIROPRACTIC OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-751-7700
Mailing Address - Street 1:416 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3841
Mailing Address - Country:US
Mailing Address - Phone:631-751-7700
Mailing Address - Fax:631-751-7096
Practice Address - Street 1:416 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3841
Practice Address - Country:US
Practice Address - Phone:631-751-7700
Practice Address - Fax:631-751-7096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-26
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002824111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01738370Medicaid
NY01738370Medicaid