Provider Demographics
NPI:1629113709
Name:KRAVTSOV, VALERIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:VALERIAN
Middle Name:
Last Name:KRAVTSOV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 RIDGE AVE
Mailing Address - Street 2:#203
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3696
Mailing Address - Country:US
Mailing Address - Phone:847-361-4971
Mailing Address - Fax:847-296-2922
Practice Address - Street 1:1645 S DES PLAINES RIVER RD
Practice Address - Street 2:SUITE 14
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018
Practice Address - Country:US
Practice Address - Phone:847-361-4971
Practice Address - Fax:847-296-2922
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1622831OtherBCBS PROVIDER #