1023049673 NPI number — EDWIN KAZUO KIKUCHI MSW

Table of content: EDWIN KAZUO KIKUCHI MSW (NPI 1023049673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023049673 NPI number — EDWIN KAZUO KIKUCHI MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIKUCHI
Provider First Name:
EDWIN
Provider Middle Name:
KAZUO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023049673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUNNING SPRINGS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92382-0033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-867-2122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29099HOSPITAL ROAD
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-337-8219
Provider Business Practice Location Address Fax Number:
909-337-8920
Provider Enumeration Date:
07/05/2006

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: 1041C0700X , with the licence number:  LCS4695 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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