Provider Demographics
NPI:1497059844
Name:FEDOTENKO, VIKTOR (CMT)
Entity Type:Individual
Prefix:
First Name:VIKTOR
Middle Name:
Last Name:FEDOTENKO
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2709
Mailing Address - Country:US
Mailing Address - Phone:916-596-0682
Mailing Address - Fax:
Practice Address - Street 1:5535 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2709
Practice Address - Country:US
Practice Address - Phone:916-596-0682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist