Provider Demographics
NPI:1457947624
Name:KRIVOSHIYSKI, PETAR STOYANOV
Entity Type:Individual
Prefix:
First Name:PETAR
Middle Name:STOYANOV
Last Name:KRIVOSHIYSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 W EASTWOOD AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3175
Mailing Address - Country:US
Mailing Address - Phone:773-414-2789
Mailing Address - Fax:
Practice Address - Street 1:6050 W EASTWOOD AVE APT 106
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3175
Practice Address - Country:US
Practice Address - Phone:773-414-2789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.016981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist