Provider Demographics
NPI:1700250958
Name:KIBA, YASUNORI (LAC)
Entity Type:Individual
Prefix:
First Name:YASUNORI
Middle Name:
Last Name:KIBA
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 1:1250 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2804
Mailing Address - Country:US
Mailing Address - Phone:651-261-5007
Mailing Address - Fax:
Practice Address - Street 1:1208 HAMPEL ST APT 2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602
Practice Address - Country:US
Practice Address - Phone:651-261-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-25
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16726171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist