Provider Demographics
NPI:1023408580
Name:IWAMOTO ENTERPRISES, INC.
Entity type:Organization
Organization Name:IWAMOTO ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:TAKEO
Authorized Official - Last Name:IWAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-506-6861
Mailing Address - Street 1:5451 LAUREL CANYON BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2180
Mailing Address - Country:US
Mailing Address - Phone:818-506-6861
Mailing Address - Fax:818-506-3643
Practice Address - Street 1:5451 LAUREL CANYON BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2180
Practice Address - Country:US
Practice Address - Phone:818-506-6861
Practice Address - Fax:818-506-3643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFAC00046448292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory