Provider Demographics
NPI:1760766448
Name:KUBOTA, TYLER TAKAYUKI (LAC)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:TAKAYUKI
Last Name:KUBOTA
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 1:3686 S CENTINELA AVE
Mailing Address - Street 2:APT. 21
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3154
Mailing Address - Country:US
Mailing Address - Phone:424-250-8272
Mailing Address - Fax:
Practice Address - Street 1:11965 VENICE BLVD
Practice Address - Street 2:STE 209
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3979
Practice Address - Country:US
Practice Address - Phone:424-250-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11038171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist