Provider Demographics
NPI:1619575800
Name:SHIMUNOV, ROMAN (LAC)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:SHIMUNOV
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 1:9823 HORACE HARDING EXPY APT 15C
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4269
Mailing Address - Country:US
Mailing Address - Phone:347-267-9815
Mailing Address - Fax:
Practice Address - Street 1:1534 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221
Practice Address - Country:US
Practice Address - Phone:347-267-9815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002839171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist