Provider Demographics
NPI:1215280276
Name:EAST END SPORTS CHIROPRACTIC, PC
Entity type:Organization
Organization Name:EAST END SPORTS CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PETRUCCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-725-8209
Mailing Address - Street 1:PO BOX 2902
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0401
Mailing Address - Country:US
Mailing Address - Phone:631-725-8209
Mailing Address - Fax:631-919-1592
Practice Address - Street 1:39 DIVISION ST
Practice Address - Street 2:GROUND FLR, 2ND OFFC FROM REAR
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-3156
Practice Address - Country:US
Practice Address - Phone:631-725-8209
Practice Address - Fax:631-919-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010203-1111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU87714Medicare UPIN