Provider Demographics
NPI:1144435934
Name:POLOUKINE, ALEXANDER
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:POLOUKINE
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 1:710 SW BELMONT CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6337
Mailing Address - Country:US
Mailing Address - Phone:772-418-2220
Mailing Address - Fax:
Practice Address - Street 1:1701 SE HILLMOOR DR
Practice Address - Street 2:SUITE 1A
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7552
Practice Address - Country:US
Practice Address - Phone:772-337-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA40421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist