Provider Demographics
NPI:1497984322
Name:ISLAND ACTIVE RELEASE AND SPORTS CHIROPRACTIC
Entity Type:Organization
Organization Name:ISLAND ACTIVE RELEASE AND SPORTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:TOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:917-755-7088
Mailing Address - Street 1:8 CORTELYOU AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2104
Mailing Address - Country:US
Mailing Address - Phone:917-755-7088
Mailing Address - Fax:973-777-6963
Practice Address - Street 1:91 FOSTER RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3014
Practice Address - Country:US
Practice Address - Phone:917-755-7088
Practice Address - Fax:973-777-6963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009584-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty