Provider Demographics
NPI:1164740924
Name:TAKATA, MARK TAKASHI (MS L,AC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TAKASHI
Last Name:TAKATA
Suffix:
Gender:M
Credentials:MS L,AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:EL GRANADA
Mailing Address - State:CA
Mailing Address - Zip Code:94018-0416
Mailing Address - Country:US
Mailing Address - Phone:650-726-5179
Mailing Address - Fax:650-726-3388
Practice Address - Street 1:455 AVENUE ALHAMBRA
Practice Address - Street 2:
Practice Address - City:EL GRANADA
Practice Address - State:CA
Practice Address - Zip Code:94018
Practice Address - Country:US
Practice Address - Phone:650-726-5179
Practice Address - Fax:650-726-3388
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4807171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist