Provider Demographics
NPI:1801402409
Name:KIMURA, MASAMI
Entity Type:Individual
Prefix:
First Name:MASAMI
Middle Name:
Last Name:KIMURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 E BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-2302
Mailing Address - Country:US
Mailing Address - Phone:714-349-6043
Mailing Address - Fax:
Practice Address - Street 1:622 E BERKELEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-2302
Practice Address - Country:US
Practice Address - Phone:714-349-6043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
43424OtherMASSAGE THERAPIST