Provider Demographics
NPI:1134667959
Name:MIZUTARI, CLAYTON (BA)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:MIZUTARI
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-2006
Mailing Address - Country:US
Mailing Address - Phone:714-636-6286
Mailing Address - Fax:
Practice Address - Street 1:12900 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2006
Practice Address - Country:US
Practice Address - Phone:714-636-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator