Provider Demographics
NPI:1770977613
Name:KORNEYCHUK, NIKOLAY
Entity type:Individual
Prefix:
First Name:NIKOLAY
Middle Name:
Last Name:KORNEYCHUK
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 1:1780 COMPTON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-8482
Mailing Address - Country:US
Mailing Address - Phone:864-804-4510
Mailing Address - Fax:
Practice Address - Street 1:111 S CONGRESS ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-1836
Practice Address - Country:US
Practice Address - Phone:803-684-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC337700390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program