Provider Demographics
NPI:1760180913
Name:ITOH, KEN WINSTON CLOMA
Entity Type:Individual
Prefix:
First Name:KEN WINSTON
Middle Name:CLOMA
Last Name:ITOH
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 1:4912 HAVERWOOD LN APT 911D
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-4422
Mailing Address - Country:US
Mailing Address - Phone:575-631-0277
Mailing Address - Fax:
Practice Address - Street 1:5425 W SPRING CREEK PKWY STE 270
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-4317
Practice Address - Country:US
Practice Address - Phone:972-656-0431
Practice Address - Fax:972-801-2191
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT6177225100000X
TX1368766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist