Provider Demographics
NPI:1518549914
Name:SHIBAO, BRUCE KAZUFUSA (CMT, GCFP)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:KAZUFUSA
Last Name:SHIBAO
Suffix:
Gender:M
Credentials:CMT, GCFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 LAIDLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-3040
Mailing Address - Country:US
Mailing Address - Phone:415-584-4520
Mailing Address - Fax:
Practice Address - Street 1:544 LAIDLEY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-3040
Practice Address - Country:US
Practice Address - Phone:415-269-4579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty