Provider Demographics
NPI:1891838538
Name:CHIROPRACTIC OF STONY BROOK PLLC
Entity Type:Organization
Organization Name:CHIROPRACTIC OF STONY BROOK PLLC
Other - Org Name:PORT JEFF STATION CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BONASERA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-828-4545
Mailing Address - Street 1:1041 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-6000
Mailing Address - Country:US
Mailing Address - Phone:631-828-4545
Mailing Address - Fax:631-642-1070
Practice Address - Street 1:1041 ROUT 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-828-4545
Practice Address - Fax:631-642-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
NYX005301-1261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01738361Medicaid
NYX28952Medicare ID - Type Unspecified