Provider Demographics
NPI:1831663210
Name:POPOWICH, VICTORIA M (LMT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
Last Name:POPOWICH
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 1:17329 SHELDON DUNES DR
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9362
Mailing Address - Country:US
Mailing Address - Phone:616-552-3389
Mailing Address - Fax:
Practice Address - Street 1:10500 CHICAGO DR STE 65
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-8745
Practice Address - Country:US
Practice Address - Phone:616-552-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010419225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist