Provider Demographics
NPI:1366482762
Name:OVCHINNIKOV, YURI (LAC)
Entity Type:Individual
Prefix:
First Name:YURI
Middle Name:
Last Name:OVCHINNIKOV
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EARHART
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3335
Mailing Address - Country:US
Mailing Address - Phone:323-428-9846
Mailing Address - Fax:
Practice Address - Street 1:8205 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5963
Practice Address - Country:US
Practice Address - Phone:323-656-5115
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6960171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0069600Medicaid