Provider Demographics
NPI:1508042128
Name:MATSUMOTO, KIIKO (LIC AC)
Entity Type:Individual
Prefix:
First Name:KIIKO
Middle Name:
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1804
Mailing Address - Country:US
Mailing Address - Phone:617-630-9738
Mailing Address - Fax:
Practice Address - Street 1:1647 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2229
Practice Address - Country:US
Practice Address - Phone:617-630-9738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA120171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist