Provider Demographics
NPI:1255703807
Name:PATCHOGUE-MEDFORD PT & CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:PATCHOGUE-MEDFORD PT & CHIROPRACTIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:TESORIERO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-617-5040
Mailing Address - Street 1:2103 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1317
Mailing Address - Country:US
Mailing Address - Phone:631-242-4500
Mailing Address - Fax:631-242-0885
Practice Address - Street 1:105 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1223
Practice Address - Country:US
Practice Address - Phone:631-617-5040
Practice Address - Fax:631-617-5559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004766111N00000X
NY025310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty