Provider Demographics
NPI:1558759308
Name:OGINO, MAYUMI
Entity Type:Individual
Prefix:
First Name:MAYUMI
Middle Name:
Last Name:OGINO
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 1:817 DUKE DR APT 107
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3970
Mailing Address - Country:US
Mailing Address - Phone:307-399-3883
Mailing Address - Fax:
Practice Address - Street 1:2751 2ND AVE N RM 115
Practice Address - Street 2:MAIL STOP 9013
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-6060
Practice Address - Country:US
Practice Address - Phone:701-777-0723
Practice Address - Fax:701-777-8058
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010009592255A2300X
ND691-152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer