MEDICARE: VADIM DEKHTYAR L. AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist		IL

General Provider Information

NPI Number	:	1750422580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VADIM DEKHTYAR L. AC.

Provider Business Mailing Address
First Line	:	6211 LINCOLN AVE UNIT 408
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2863
Country	:	US
Telephone Number	:	847-965-0664
Fax Number	:	847-724-4488

Provider Business Practice Location Address
First Line	:	3633 W LAKE AVE STE 303
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60026-5803
Country	:	US
Telephone Number	:	847-724-1777
Fax Number	:	847-724-4488

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/08/2007

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