Provider Demographics
NPI:1184353310
Name:KENVELO2
Entity type:Organization
Organization Name:KENVELO2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TSYRULNYKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-915-5665
Mailing Address - Street 1:66 W FLAGLER ST STE 900
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-1807
Mailing Address - Country:US
Mailing Address - Phone:414-915-5665
Mailing Address - Fax:
Practice Address - Street 1:66 W FLAGLER ST STE 900
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-1807
Practice Address - Country:US
Practice Address - Phone:414-915-5665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-04
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty