Provider Demographics
NPI:1447593710
Name:ADVANTAGE MASSAGE THERAPY, CHIROPRACTIC & ACUPUNCTURE, PLLC
Entity Type:Organization
Organization Name:ADVANTAGE MASSAGE THERAPY, CHIROPRACTIC & ACUPUNCTURE, PLLC
Other - Org Name:LONG ISLAND FUNCTIONAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-404-6377
Mailing Address - Street 1:193 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4080
Mailing Address - Country:US
Mailing Address - Phone:631-404-6377
Mailing Address - Fax:
Practice Address - Street 1:535 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3713
Practice Address - Country:US
Practice Address - Phone:631-404-6377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008902111N00000X
NY004878171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty