Provider Demographics
NPI:1073850079
Name:OTOMO, JUSTIN MICHAEL (LAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:OTOMO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23162 LOS ALISOS BLVD STE 102B
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7861
Mailing Address - Country:US
Mailing Address - Phone:310-339-1374
Mailing Address - Fax:949-951-1747
Practice Address - Street 1:23162 LOS ALISOS BLVD STE 102B
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-7861
Practice Address - Country:US
Practice Address - Phone:310-339-1374
Practice Address - Fax:949-951-1747
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12022171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist