Provider Demographics
NPI:1942468160
Name:REBORN CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:REBORN CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-746-4777
Mailing Address - Street 1:7 08 149TH STREET
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357
Mailing Address - Country:US
Mailing Address - Phone:718-746-4777
Mailing Address - Fax:718-746-4738
Practice Address - Street 1:7 08 149TH STREET
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357
Practice Address - Country:US
Practice Address - Phone:718-746-4777
Practice Address - Fax:718-746-4738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXX003564-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052712Medicare PIN