Healthcare Provider Details

I. General information

NPI: 1477045268
Provider Name (Legal Business Name): MRS. KRISTINA PETROVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 FINLEY RD
ROSTRAVER TOWNSHIP PA
15012-1994
US

IV. Provider business mailing address

6700 WASHINGTON AVE S
EDEN PRAIRIE MN
55344-3405
US

V. Phone/Fax

Practice location:
  • Phone: 724-489-9565
  • Fax: 724-489-9566
Mailing address:
  • Phone: 612-351-1529
  • Fax: 952-285-3980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberF03740
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: