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1041 Rout 112, Port Jefferson Station, NY 11776 | |
(631) 828-4545 | |
(631) 642-1070 |
Full Name | |
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Type | Facility |
Speciality | Clinic/center |
Location | 1041 Rout 112, Port Jefferson Station, New York |
Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
Identifier | Type | State | Issuer |
---|---|---|---|
1891838538 | NPI | - | NPPES |
01738361 | Medicaid | NY |
Taxonomy | Type | License (State) | Status |
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111N00000X | Chiropractor | (* (Not Available)) | Secondary |
261Q00000X | Clinic/center | X005301-1 (New York) | Primary |
Provider Name | Gregory N. Bonasera |
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Provider Type | Practitioner - Chiropractic |
Provider Identifiers | NPI Number: 1841374352 PECOS PAC ID: 9739427618 Enrollment ID: I20190401001187 |
Mailing Address | Practice Location Address |
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1041 Route 112, Port Jefferson Station, NY 11776-6000 Ph: (631) 828-4545 | 1041 Rout 112, Port Jefferson Station, NY 11776 Ph: (631) 828-4545 |