Provider Demographics
NPI:1881179323
Name:TAKASAKI, DAVID INOUYE (ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:INOUYE
Last Name:TAKASAKI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 N 500 W APT 102
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2601
Mailing Address - Country:US
Mailing Address - Phone:801-388-2710
Mailing Address - Fax:
Practice Address - Street 1:331 SAB
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-422-2096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10890883-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer