Provider Demographics
NPI:1043913908
Name:BALYKOV, ANDREY (ATC ATL)
Entity Type:Individual
Prefix:MR
First Name:ANDREY
Middle Name:
Last Name:BALYKOV
Suffix:
Gender:M
Credentials:ATC ATL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8099 COLLEGE PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2204 OASIS PALM CIR APT 405
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-3391
Practice Address - Country:US
Practice Address - Phone:239-560-9185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL47092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer