Provider Demographics
NPI:1659576247
Name:KICHAKOV, ALEXANDER (LAT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:KICHAKOV
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N CRESCENT LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-6016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:0 S 050 WINFIELD ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-653-4743
Practice Address - Fax:630-653-4912
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer