Healthcare Provider Details

I. General information

NPI: 1790232890
Provider Name (Legal Business Name): YELENA KUDRYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N NEVADA AVE 4
COLORADO SPRINGS CO
80903-5004
US

IV. Provider business mailing address

1134 ADAMS DR
COLORADO SPRINGS CO
80904-1208
US

V. Phone/Fax

Practice location:
  • Phone: 719-375-5165
  • Fax:
Mailing address:
  • Phone: 719-375-5165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0016995
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: