Provider Demographics
NPI:1982859336
Name:KITANO, ICHIRO (MED, ATC)
Entity Type:Individual
Prefix:MR
First Name:ICHIRO
Middle Name:
Last Name:KITANO
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 N OLD COACHMAN RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-2321
Mailing Address - Country:US
Mailing Address - Phone:215-341-7736
Mailing Address - Fax:
Practice Address - Street 1:651 N OLD COACHMAN RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2321
Practice Address - Country:US
Practice Address - Phone:215-341-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-27
Last Update Date:2008-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL19142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer