Provider Demographics
NPI:1497399091
Name:SANO, NISHIKI JADE
Entity Type:Individual
Prefix:
First Name:NISHIKI
Middle Name:JADE
Last Name:SANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 NEIL ARMSTRONG ST UNIT 207
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2019
Mailing Address - Country:US
Mailing Address - Phone:626-512-5130
Mailing Address - Fax:
Practice Address - Street 1:23430 HAWTHORNE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4777
Practice Address - Country:US
Practice Address - Phone:310-465-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist