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NPI Code Detail

MEDICARE: MR. STANISLAV KONONOV LMT

MEDICARE: MR. STANISLAV KONONOV LMT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225700000XMassage Therapist3048-146WI

General Provider Information

NPI Number : 1922748169
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. STANISLAV KONONOV LMT
Provider Business Mailing Address
First Line : 2222 E BELLEVIEW PL APT 104
Second Line :
City : MILWAUKEE
State : WI
Zip : 53211-4005
Country : US
Telephone Number : 414-334-1023
Fax Number :
Provider Business Practice Location Address
First Line : 5215 N IRONWOOD RD STE 104
Second Line :
City : GLENDALE
State : WI
Zip : 53217-4908
Country : US
Telephone Number : 414-334-1023
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/29/2022
Last Update Date : 03/29/2022

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