Provider Demographics
NPI:1043789456
Name:NITAKE, MARK ADAM (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ADAM
Last Name:NITAKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 BULOVA ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-1468
Mailing Address - Country:US
Mailing Address - Phone:131-094-7220
Mailing Address - Fax:
Practice Address - Street 1:4720 BULOVA ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1468
Practice Address - Country:US
Practice Address - Phone:310-947-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist