Provider Demographics
NPI:1609221738
Name:NOMURA, RONALD (LMT, BCTMB, CPMT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:NOMURA
Suffix:
Gender:M
Credentials:LMT, BCTMB, CPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1453
Mailing Address - Country:US
Mailing Address - Phone:248-446-2639
Mailing Address - Fax:
Practice Address - Street 1:555 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1453
Practice Address - Country:US
Practice Address - Phone:248-446-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist