Provider Demographics
NPI:1881459295
Name:FUKUSHIMA, BRENT (SRNA)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:FUKUSHIMA
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 S SEPULVEDA BLVD APT 216
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6848
Mailing Address - Country:US
Mailing Address - Phone:808-258-1401
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program