Healthcare Provider Details

I. General information

NPI: 1477813871
Provider Name (Legal Business Name): GEORGE KOUKOUVES L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36800 N. SIDEWINDER A-8
CAREFREE AZ
85377
US

IV. Provider business mailing address

15734 E SYCAMORE DR
FOUNTAIN HILLS AZ
85268-4371
US

V. Phone/Fax

Practice location:
  • Phone: 480-363-0091
  • Fax: 480-575-1181
Mailing address:
  • Phone: 480-836-6888
  • Fax: 480-836-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-03432P
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMT-03432P
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: