Provider Demographics
NPI:1811254071
Name:EAST PARK CHIROPRACTIC
Entity type:Organization
Organization Name:EAST PARK CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:GRUSHACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:516-431-7972
Mailing Address - Street 1:714 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-2605
Mailing Address - Country:US
Mailing Address - Phone:516-431-7972
Mailing Address - Fax:516-431-7944
Practice Address - Street 1:714 E PARK AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2605
Practice Address - Country:US
Practice Address - Phone:516-431-7972
Practice Address - Fax:516-431-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3174111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1972543320OtherNPI
NY1407896897OtherNPI
NY1407896897OtherNPI
NYX18471Medicare PIN