Healthcare Provider Details

I. General information

NPI: 1508335258
Provider Name (Legal Business Name): STANISLAV KUPCHENKO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2018
Last Update Date: 11/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W 29TH ST RM 901
NEW YORK NY
10001-5757
US

IV. Provider business mailing address

1815 215TH ST APT 7P
BAYSIDE NY
11360-2138
US

V. Phone/Fax

Practice location:
  • Phone: 917-338-6268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number043755-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: