Provider Demographics
NPI:1255903332
Name:PINEDA, JONNATHAN M (LMT)
Entity type:Individual
Prefix:
First Name:JONNATHAN
Middle Name:M
Last Name:PINEDA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 MAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-1957
Mailing Address - Country:US
Mailing Address - Phone:631-369-4323
Mailing Address - Fax:631-369-4325
Practice Address - Street 1:189 MAIN RD STE A
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1957
Practice Address - Country:US
Practice Address - Phone:631-369-4323
Practice Address - Fax:631-369-4325
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030875-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1447250261OtherNPI