Basic Information
| Provider Information | |||||||||
| NPI: | 1609930650 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHBAY BACK TO WORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | COPIAGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117264904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318424606 | ||||||||
| FaxNumber: | 6318420803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | COPIAGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117264904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318424606 | ||||||||
| FaxNumber: | 6318420803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALONIA-BELLUCCI | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6318424606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 009181 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.