Healthcare Provider Details

I. General information

NPI: 1699118455
Provider Name (Legal Business Name): KOSTYANTYN SHKILNYY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48254 ELLINGTON DRIVE
MACOMB TOWNSHIP MI
48044
US

IV. Provider business mailing address

48254 ELLINGTON DR
MACOMB MI
48044-2279
US

V. Phone/Fax

Practice location:
  • Phone: 586-909-0891
  • Fax:
Mailing address:
  • Phone: 586-909-0891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501000299
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: