Healthcare Provider Details

I. General information

NPI: 1275082067
Provider Name (Legal Business Name): STANISLAV KUKUSHKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17221 SE DIVISION ST
PORTLAND OR
97236
US

IV. Provider business mailing address

17221 SE DIVISION ST
PORTLAND OR
97236
US

V. Phone/Fax

Practice location:
  • Phone: 503-760-0778
  • Fax:
Mailing address:
  • Phone: 503-760-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number21741
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: