1053960286 NPI number — KYLE HIROMI HATANAKA LAC

Table of content: KYLE HIROMI HATANAKA LAC (NPI 1053960286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053960286 NPI number — KYLE HIROMI HATANAKA LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATANAKA
Provider First Name:
KYLE
Provider Middle Name:
HIROMI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HATANAKA
Provider Other First Name:
KYLE
Provider Other Middle Name:
HIROMI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053960286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5112 NE 47TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97218-2066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-515-1064
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9450 #120 FAIRVIEW AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-515-1064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)