MEDICARE: POLINA V SVISTUNOV LMT

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	225700000X	Massage Therapist	MA60921435	WA

General Provider Information

NPI Number	:	1952868234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POLINA V SVISTUNOV LMT

Provider Business Mailing Address
First Line	:	16500 SE 15TH ST STE 160
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-9666
Country	:	US
Telephone Number	:	360-718-7944
Fax Number	:	360-718-7931

Provider Business Practice Location Address
First Line	:	16500 SE 15TH ST STE 160
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-9666
Country	:	US
Telephone Number	:	360-718-7944
Fax Number	:	360-718-7931

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

Provider Enumeration Date	:	02/22/2019
Last Update Date	:	02/22/2019

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