=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457511172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEV SUDAKOV DC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2008
-----------------------------------------------------
Last Update Date | 07/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 S OCEAN DR STE 230
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33019-2930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-391-7864
-----------------------------------------------------
Fax | 954-391-8468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3800 S OCEAN DR STE 230
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33019-2930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-391-7864
-----------------------------------------------------
Fax | 954-391-8468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEV SUDAKOV
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 954-391-7864
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH8450
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------