Provider Demographics
NPI:1689974990
Name:CERNOV, VLADIMIR IVANOVICH (MASSAGE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:IVANOVICH
Last Name:CERNOV
Suffix:
Gender:M
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:VLADIMIR
Other - Middle Name:IVANOVICH
Other - Last Name:CERNOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:VLAD'S MASSAGE
Mailing Address - Street 1:3815 N PEARL ST
Mailing Address - Street 2:NONE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2619
Mailing Address - Country:US
Mailing Address - Phone:253-761-8053
Mailing Address - Fax:
Practice Address - Street 1:3815 N PEARL ST
Practice Address - Street 2:NONE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-2619
Practice Address - Country:US
Practice Address - Phone:253-761-8053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00025393174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0252162OtherDEPARTMENT OF LABOR AND INDUSTRIES