Provider Demographics
NPI:1821076852
Name:KAMINSKY, ILYA (RPT, DC)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:KAMINSKY
Suffix:
Gender:M
Credentials:RPT, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 ACHILLES DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-1623
Mailing Address - Country:US
Mailing Address - Phone:323-966-2676
Mailing Address - Fax:323-966-2677
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5702
Practice Address - Country:US
Practice Address - Phone:323-966-2676
Practice Address - Fax:323-966-2677
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19092225100000X
CADC25455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC25455OtherSTATE LICENSE #
CAPT19092OtherSTATE LICENSE #
CAPT19092OtherSTATE LICENSE #
CADC25455AMedicare PIN
CADC25455BMedicare PIN
CAPT19092Medicare PIN