Provider Demographics
NPI:1073055687
Name:BOGDANOV, ALEKSEY (LMT)
Entity Type:Individual
Prefix:
First Name:ALEKSEY
Middle Name:
Last Name:BOGDANOV
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 COUNCIL BLUFFS WAY
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7509
Mailing Address - Country:US
Mailing Address - Phone:360-773-2602
Mailing Address - Fax:360-260-4849
Practice Address - Street 1:3021 NE 72ND DR
Practice Address - Street 2:#15
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7300
Practice Address - Country:US
Practice Address - Phone:360-260-6903
Practice Address - Fax:360-260-4849
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60609990225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60609990OtherSTATE MASSAGE LICENSE