Provider Demographics
NPI:1104249853
Name:TOMILOV, MAKSIM
Entity type:Individual
Prefix:
First Name:MAKSIM
Middle Name:
Last Name:TOMILOV
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 1:1636 S 370TH PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-7587
Mailing Address - Country:US
Mailing Address - Phone:253-561-5099
Mailing Address - Fax:
Practice Address - Street 1:7315 212TH ST SW STE 202
Practice Address - Street 2:(206)241-3836
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-361-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60255467225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist