Provider Demographics
NPI:1093055238
Name:TAKAICHI, FORD SCOTT (ABO)
Entity Type:Individual
Prefix:
First Name:FORD
Middle Name:SCOTT
Last Name:TAKAICHI
Suffix:
Gender:M
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 CLARES ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2555
Mailing Address - Country:US
Mailing Address - Phone:831-477-4900
Mailing Address - Fax:831-477-4909
Practice Address - Street 1:3555 CLARES ST
Practice Address - Street 2:SUITE H
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2555
Practice Address - Country:US
Practice Address - Phone:831-477-4900
Practice Address - Fax:831-477-4909
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA183993156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician