Provider Demographics
NPI:1053467555
Name:TAKAIWA, MASAYASU (MA, ATC)
Entity Type:Individual
Prefix:MR
First Name:MASAYASU
Middle Name:
Last Name:TAKAIWA
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:31245 WELLINGTON DR APT 23301
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-4236
Mailing Address - Country:US
Mailing Address - Phone:734-395-7540
Mailing Address - Fax:734-487-5173
Practice Address - Street 1:799 N HEWITT RD
Practice Address - Street 2:142 CONVOCATION CENTER
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1701
Practice Address - Country:US
Practice Address - Phone:734-487-5179
Practice Address - Fax:734-487-5173
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer