Provider Demographics
NPI:1558953885
Name:TAKEKOSHI, NICHOLAS JAMES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:TAKEKOSHI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 CALLE VALLARTA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3523
Mailing Address - Country:US
Mailing Address - Phone:714-656-5321
Mailing Address - Fax:
Practice Address - Street 1:485 E 17TH ST STE 650
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-4706
Practice Address - Country:US
Practice Address - Phone:949-722-7374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist