Provider Demographics
NPI:1679878078
Name:STANCHAK, MIRA TATYANA (MSAOM)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:TATYANA
Last Name:STANCHAK
Suffix:
Gender:F
Credentials:MSAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COTTAGE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1513
Mailing Address - Country:US
Mailing Address - Phone:671-824-0746
Mailing Address - Fax:
Practice Address - Street 1:65 COTTAGE ST APT 1
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-1513
Practice Address - Country:US
Practice Address - Phone:671-824-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist