Provider Demographics
NPI:1215798384
Name:KIRICHENKO, ALEXANDER A (LMT)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:A
Last Name:KIRICHENKO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13770 BEACH BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7227
Mailing Address - Country:US
Mailing Address - Phone:904-539-3352
Mailing Address - Fax:904-539-3351
Practice Address - Street 1:13770 BEACH BLVD STE 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7227
Practice Address - Country:US
Practice Address - Phone:904-539-3352
Practice Address - Fax:904-539-3351
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA89591225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist