Provider Demographics
NPI:1063267003
Name:RECHETNIKOV, ROUSLAN PETROVICH
Entity type:Individual
Prefix:
First Name:ROUSLAN
Middle Name:PETROVICH
Last Name:RECHETNIKOV
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 1:123 HEDGEROW CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-4231
Mailing Address - Country:US
Mailing Address - Phone:419-902-8326
Mailing Address - Fax:
Practice Address - Street 1:2420 LAKE WHEELER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2614
Practice Address - Country:US
Practice Address - Phone:419-902-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7404225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist