Provider Demographics
NPI:1750422580
Name:DEKHTYAR, VADIM (L AC)
Entity type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:DEKHTYAR
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6211 LINCOLN AVE UNIT 408
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2863
Mailing Address - Country:US
Mailing Address - Phone:847-965-0664
Mailing Address - Fax:847-724-4488
Practice Address - Street 1:3633 W LAKE AVE STE 303
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5803
Practice Address - Country:US
Practice Address - Phone:847-724-1777
Practice Address - Fax:847-724-4488
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist