Healthcare Provider Details

I. General information

NPI: 1730538620
Provider Name (Legal Business Name): ROSTISLAV E KECHEDZHI LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 DEVONSHIRE ST
BOSTON MA
02110-1407
US

IV. Provider business mailing address

9 FULLER RD APT 6
FOXBORO MA
02035-2086
US

V. Phone/Fax

Practice location:
  • Phone: 617-654-8960
  • Fax:
Mailing address:
  • Phone: 617-433-7389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number11859
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: