Healthcare Provider Details

I. General information

NPI: 1386372407
Provider Name (Legal Business Name): FARKHOD F USMANOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 8TH AVE RM 811
NEW YORK NY
10018-4587
US

IV. Provider business mailing address

3250 CONEY ISLAND AVE APT 14A
BROOKLYN NY
11235-6616
US

V. Phone/Fax

Practice location:
  • Phone: 845-809-8300
  • Fax:
Mailing address:
  • Phone: 347-777-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number026334
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: