Provider Demographics
NPI:1487023503
Name:IKAWA, TOMOMI (DC)
Entity Type:Individual
Prefix:
First Name:TOMOMI
Middle Name:
Last Name:IKAWA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 4TH ST. E.
Mailing Address - Street 2:SUITE 310
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 4TH ST. E.
Practice Address - Street 2:SUITE 310
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor