Healthcare Provider Details

I. General information

NPI: 1205724283
Provider Name (Legal Business Name): VITALIY KOPYTKO L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 N LINCOLN AVE
CHICAGO IL
60625-2102
US

IV. Provider business mailing address

4555 N LINCOLN AVE
CHICAGO IL
60625-2102
US

V. Phone/Fax

Practice location:
  • Phone: 773-273-6736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.001685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: