Basic Information
| Provider Information | |||||||||
| NPI: | 1568010486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAKHAROVA | ||||||||
| FirstName: | KSENIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 VILLAGE GREEN LN APT 2064 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483282472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488201089 | ||||||||
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| Practice Location | |||||||||
| Address1: | 955 CAMPUS DR N | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483282754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484756300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2019 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
No ID Information.