Healthcare Provider Details

I. General information

NPI: 1619365558
Provider Name (Legal Business Name): VERA PLUSCHAKOV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S GARDEN DR
LYNDEN WA
98264-1022
US

IV. Provider business mailing address

201 S GARDEN DR
LYNDEN WA
98264-1022
US

V. Phone/Fax

Practice location:
  • Phone: 360-656-6890
  • Fax: 360-656-6890
Mailing address:
  • Phone: 360-656-6890
  • Fax: 360-656-6890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberA750374
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: