Provider Demographics
NPI:1639633514
Name:KAWAGUCHI, KOKI (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KOKI
Middle Name:
Last Name:KAWAGUCHI
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SLIPPERY ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:16057-1150
Mailing Address - Country:US
Mailing Address - Phone:724-290-5647
Mailing Address - Fax:
Practice Address - Street 1:2497 HARLANSBURG RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-9723
Practice Address - Country:US
Practice Address - Phone:724-658-8940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
PART0074842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty