Provider Demographics
NPI:1568768885
Name:KUBOTA, KEISUKE
Entity Type:Individual
Prefix:
First Name:KEISUKE
Middle Name:
Last Name:KUBOTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 KOGANEHARA
Mailing Address - Street 2:
Mailing Address - City:MATSUDO
Mailing Address - State:CHIBA
Mailing Address - Zip Code:2700021
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81840 AVENUE 46
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3936
Practice Address - Country:US
Practice Address - Phone:760-391-6999
Practice Address - Fax:760-391-6998
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator