Healthcare Provider Details

I. General information

NPI: 1881206522
Provider Name (Legal Business Name): IVAN KUZNETSOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2020
Last Update Date: 08/22/2020
Certification Date: 08/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34585 US HIGHWAY 59 SE
ERSKINE MN
56535-9465
US

IV. Provider business mailing address

34585 US HIGHWAY 59 SE
ERSKINE MN
56535-9465
US

V. Phone/Fax

Practice location:
  • Phone: 218-902-0653
  • Fax:
Mailing address:
  • Phone: 218-902-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number383545
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: