Provider Demographics
NPI:1720368061
Name:PETROVA-POLLARD, LARISA PAVLOVNA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:LARISA
Middle Name:PAVLOVNA
Last Name:PETROVA-POLLARD
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 HECLA ST
Mailing Address - Street 2:
Mailing Address - City:LAURIUM
Mailing Address - State:MI
Mailing Address - Zip Code:49913-2212
Mailing Address - Country:US
Mailing Address - Phone:906-337-1718
Mailing Address - Fax:
Practice Address - Street 1:416 HECLA ST
Practice Address - Street 2:
Practice Address - City:LAURIUM
Practice Address - State:MI
Practice Address - Zip Code:49913-2212
Practice Address - Country:US
Practice Address - Phone:906-337-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/C-18/00172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/C-18/00OtherRUSSION CERTIFICATE