Provider Demographics
NPI:1649004359
Name:IMAI, SHINO
Entity type:Individual
Prefix:
First Name:SHINO
Middle Name:
Last Name:IMAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9712 ADMIRAL EMERSON AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1318
Mailing Address - Country:US
Mailing Address - Phone:505-903-1252
Mailing Address - Fax:
Practice Address - Street 1:9712 ADMIRAL EMERSON AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1318
Practice Address - Country:US
Practice Address - Phone:505-903-1252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT8676225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist