Provider Demographics
NPI:1699118455
Name:SHKILNYY, KOSTYANTYN
Entity type:Individual
Prefix:
First Name:KOSTYANTYN
Middle Name:
Last Name:SHKILNYY
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 1:48254 ELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2279
Mailing Address - Country:US
Mailing Address - Phone:586-909-0891
Mailing Address - Fax:
Practice Address - Street 1:48254 ELLINGTON DRIVE
Practice Address - Street 2:
Practice Address - City:MACOMB TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48044
Practice Address - Country:US
Practice Address - Phone:586-909-0891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000299225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist