Provider Demographics
NPI:1588949721
Name:CHIROPRACTIC SPORT JOINT CARE
Entity type:Organization
Organization Name:CHIROPRACTIC SPORT JOINT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNICELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-477-9300
Mailing Address - Street 1:1931 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3889
Mailing Address - Country:US
Mailing Address - Phone:718-477-9300
Mailing Address - Fax:718-477-9301
Practice Address - Street 1:1931 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3889
Practice Address - Country:US
Practice Address - Phone:718-477-9300
Practice Address - Fax:718-477-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007427261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service