Provider Demographics
NPI:1710363320
Name:TKACHENKO, MARIAH (LMT)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:TKACHENKO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 E THACKER ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6431
Mailing Address - Country:US
Mailing Address - Phone:773-870-0043
Mailing Address - Fax:
Practice Address - Street 1:4956 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2640
Practice Address - Country:US
Practice Address - Phone:773-725-5835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011440111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation