1407552086 NPI number — CHRISTINA MARIE KRUCHAKOV MFTI

Table of content: CHRISTINA MARIE KRUCHAKOV MFTI (NPI 1407552086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407552086 NPI number — CHRISTINA MARIE KRUCHAKOV MFTI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUCHAKOV
Provider First Name:
CHRISTINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFTI
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCALLAN
Provider Other First Name:
CHRISTINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407552086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5550 S UNIVERSITY DR APT 7107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33328-5338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-687-3462
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 MIDDLE RIVER DR STE 114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33304-3586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-368-0882
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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