Provider Demographics
NPI:1740385327
Name:ATLANTIC CHIROPRACTIC & REHABILITATION, P.C.
Entity Type:Organization
Organization Name:ATLANTIC CHIROPRACTIC & REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:PATRICIO
Authorized Official - Last Name:CORRIDORI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:516-222-2455
Mailing Address - Street 1:2088 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1709
Mailing Address - Country:US
Mailing Address - Phone:516-222-2455
Mailing Address - Fax:516-222-2459
Practice Address - Street 1:2088 FRONT ST
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1709
Practice Address - Country:US
Practice Address - Phone:516-222-2455
Practice Address - Fax:516-222-2459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011791-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXDWPB1Medicare PIN