Provider Demographics
NPI:1356545735
Name:KISSELGOF, ALEXANDER (LIC AC)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:KISSELGOF
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4351
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0933
Mailing Address - Country:US
Mailing Address - Phone:508-693-3060
Mailing Address - Fax:
Practice Address - Street 1:20 ELM STREET
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-0933
Practice Address - Country:US
Practice Address - Phone:508-693-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA672171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist