Provider Demographics
NPI:1417127820
Name:BROOKLYN CHIROPRACTIC SPINE & SPORTS INJURY PC
Entity Type:Organization
Organization Name:BROOKLYN CHIROPRACTIC SPINE & SPORTS INJURY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BONACUSO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC; CCSP
Authorized Official - Phone:212-486-8616
Mailing Address - Street 1:570 LEXINGTON AVE
Mailing Address - Street 2:SUITE 1903
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-6837
Mailing Address - Country:US
Mailing Address - Phone:212-486-8616
Mailing Address - Fax:212-486-8621
Practice Address - Street 1:570 LEXINGTON AVE
Practice Address - Street 2:SUITE 1903
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-6837
Practice Address - Country:US
Practice Address - Phone:212-486-8616
Practice Address - Fax:212-486-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005160111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38MC00343400OtherNJ LICENSE
NY03215818Medicaid
NYX005160OtherLICENSE
NY03215818Medicaid