Provider Demographics
NPI:1730380643
Name:YUDKIN, VITALIY
Entity type:Individual
Prefix:
First Name:VITALIY
Middle Name:
Last Name:YUDKIN
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 1:7260 W SUNSET BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-3417
Mailing Address - Country:US
Mailing Address - Phone:323-851-7804
Mailing Address - Fax:323-851-7878
Practice Address - Street 1:7260 W SUNSET BLVD STE 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-3417
Practice Address - Country:US
Practice Address - Phone:323-851-7804
Practice Address - Fax:323-851-7878
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC27197Medicare ID - Type UnspecifiedCHIROPRACTOR