Provider Demographics
NPI:1003362328
Name:KUKSENKO, VLADIMIR
Entity Type:Individual
Prefix:MR
First Name:VLADIMIR
Middle Name:
Last Name:KUKSENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 EATON AVE
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248
Mailing Address - Country:US
Mailing Address - Phone:360-318-5636
Mailing Address - Fax:
Practice Address - Street 1:1958 EATON AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9709
Practice Address - Country:US
Practice Address - Phone:360-318-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60525301320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities