Provider Demographics
NPI:1922633387
Name:MORITA, RYO
Entity Type:Individual
Prefix:
First Name:RYO
Middle Name:
Last Name:MORITA
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 1:12853 MAXWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-0915
Mailing Address - Country:US
Mailing Address - Phone:714-247-9646
Mailing Address - Fax:
Practice Address - Street 1:12853 MAXWELL DR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-0915
Practice Address - Country:US
Practice Address - Phone:714-247-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA96061803G78046Medicaid