Provider Demographics
NPI:1275082067
Name:KUKUSHKIN, STANISLAV
Entity Type:Individual
Prefix:
First Name:STANISLAV
Middle Name:
Last Name:KUKUSHKIN
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 1:17221 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236
Mailing Address - Country:US
Mailing Address - Phone:503-760-0778
Mailing Address - Fax:
Practice Address - Street 1:17221 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236
Practice Address - Country:US
Practice Address - Phone:503-760-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21741225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist