Provider Demographics
NPI:1871844316
Name:MIKHAIL KISSELEV, ND, PH.D, LLC
Entity Type:Organization
Organization Name:MIKHAIL KISSELEV, ND, PH.D, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:O
Authorized Official - Last Name:KISSELEV
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:206-361-0108
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:11524 15TH AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6357
Practice Address - Country:US
Practice Address - Phone:206-361-0108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIKHAIL KISSELEV, ND, PH.D, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site