Provider Demographics
NPI:1417207028
Name:LONG ISLAND CHIROPRACTIC & PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:LONG ISLAND CHIROPRACTIC & PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-360-0170
Mailing Address - Street 1:20 GILBERT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-724-1991
Mailing Address - Fax:631-724-1995
Practice Address - Street 1:20 GILBERT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-724-1991
Practice Address - Fax:631-724-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty