Provider Demographics
NPI:1780662163
Name:SPARACIO, JACK JOSEPH (MSPT COMT CFMT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:JOSEPH
Last Name:SPARACIO
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Gender:M
Credentials:MSPT COMT CFMT
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Mailing Address - Street 1:70 FOREST AVE
Mailing Address - Street 2:SUITE #2A
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:516-676-2327
Mailing Address - Fax:516-676-4960
Practice Address - Street 1:1165 NORTHERN BLVD
Practice Address - Street 2:SUITE #403
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030
Practice Address - Country:US
Practice Address - Phone:516-676-2327
Practice Address - Fax:516-676-4960
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2016-04-13
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Provider Licenses
StateLicense IDTaxonomies
NY0149561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQK811QI681Medicare PIN