Provider Demographics
NPI:1922494368
Name:KITAGUCHI, ISAO
Entity Type:Individual
Prefix:
First Name:ISAO
Middle Name:
Last Name:KITAGUCHI
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 1:108 MIDLAND AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 BOROLINE RD
Practice Address - Street 2:
Practice Address - City:SADDLE RIVER
Practice Address - State:NJ
Practice Address - Zip Code:07458-2343
Practice Address - Country:US
Practice Address - Phone:201-818-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00669800320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities