Healthcare Provider Details

I. General information

NPI: 1275084378
Provider Name (Legal Business Name): GRIGORIY KUZNETSOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 17TH AVE E
SHAKOPEE MN
55379-3372
US

IV. Provider business mailing address

906 1ST AVE E
SHAKOPEE MN
55379-1605
US

V. Phone/Fax

Practice location:
  • Phone: 952-445-5250
  • Fax:
Mailing address:
  • Phone: 952-288-9908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: