Provider Demographics
NPI:1811148687
Name:LONG ISLAND MYOFASCIAL RELEASE
Entity type:Organization
Organization Name:LONG ISLAND MYOFASCIAL RELEASE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:SANACORE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:516-650-0899
Mailing Address - Street 1:1213 WARWICK ST
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-1416
Mailing Address - Country:US
Mailing Address - Phone:516-625-3330
Mailing Address - Fax:
Practice Address - Street 1:75 PLANDOME RD STE 1
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030
Practice Address - Country:US
Practice Address - Phone:516-625-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018076-1225700000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty