Healthcare Provider Details

I. General information

NPI: 1023943065
Provider Name (Legal Business Name): MAKSIM IGOREVICH ISHANKHANOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E OLIVE AVE STE 200
BURBANK CA
91502-1821
US

IV. Provider business mailing address

11733 AVON WAY APT 101
LOS ANGELES CA
90066-7224
US

V. Phone/Fax

Practice location:
  • Phone: 213-932-0630
  • Fax:
Mailing address:
  • Phone: 213-932-0630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number35207
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: