Provider Demographics
NPI:1447433487
Name:GOTLIB, VYACHESLAV (LAC , MSAC , RN)
Entity type:Individual
Prefix:
First Name:VYACHESLAV
Middle Name:
Last Name:GOTLIB
Suffix:
Gender:M
Credentials:LAC , MSAC , RN
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Mailing Address - Street 1:37 LEGION PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2802
Mailing Address - Country:US
Mailing Address - Phone:718-442-1356
Mailing Address - Fax:
Practice Address - Street 1:225 BROADWAY
Practice Address - Street 2:#2018
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3001
Practice Address - Country:US
Practice Address - Phone:212-693-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003141171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist