Provider Demographics
NPI: | 1912415845 |
---|---|
Name: | TJB CHIROPRACTIC PLLC |
Entity Type: | Organization |
Organization Name: | TJB CHIROPRACTIC PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | THOMAS |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | BONACUSO |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | DC; CCSP |
Authorized Official - Phone: | 646-799-2010 |
Mailing Address - Street 1: | 10 HANOVER SQUARE |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW YORK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10005 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 646-799-2010 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10 HANOVER SQUARE |
Practice Address - Street 2: | |
Practice Address - City: | NEW YORK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10005 |
Practice Address - Country: | US |
Practice Address - Phone: | 646-799-2010 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-01-12 |
Last Update Date: | 2018-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | X005160 | 111NS0005X |
X005160 | 111NS0005X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111NS0005X | Chiropractic Providers | Chiropractor | Sports Physician | Group - Single Specialty |