Provider Demographics
NPI:1609903863
Name:TSUBAKIYAMA, KIYOHIDE (LAC)
Entity Type:Individual
Prefix:
First Name:KIYOHIDE
Middle Name:
Last Name:TSUBAKIYAMA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 LINCOLN BLVD # 303
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1710
Mailing Address - Country:US
Mailing Address - Phone:310-394-2340
Mailing Address - Fax:310-394-3831
Practice Address - Street 1:1227 LINCOLN BLVD # 303
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1710
Practice Address - Country:US
Practice Address - Phone:310-394-2340
Practice Address - Fax:310-394-3831
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 3953171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist