Provider Demographics
NPI:1043739790
Name:BANCHI, WAKA FUKUHARA (RD)
Entity Type:Individual
Prefix:MS
First Name:WAKA
Middle Name:FUKUHARA
Last Name:BANCHI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 MOTOR AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3448
Mailing Address - Country:US
Mailing Address - Phone:310-493-5376
Mailing Address - Fax:
Practice Address - Street 1:4315 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3448
Practice Address - Country:US
Practice Address - Phone:310-493-5376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86074618133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered