Provider Demographics
NPI:1932320207
Name:KIYAMA, DANIEL ICHIRO (LAC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ICHIRO
Last Name:KIYAMA
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 1:111 CLOUDCREST
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1323
Mailing Address - Country:US
Mailing Address - Phone:949-683-2817
Mailing Address - Fax:
Practice Address - Street 1:15541 BEACH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7104
Practice Address - Country:US
Practice Address - Phone:949-683-2817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10178171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist