1053467555 NPI number — MR. MASAYASU TAKAIWA MA, ATC

Table of content: MR. MASAYASU TAKAIWA MA, ATC (NPI 1053467555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053467555 NPI number — MR. MASAYASU TAKAIWA MA, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAKAIWA
Provider First Name:
MASAYASU
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC
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:
1053467555
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:
31245 WELLINGTON DR APT 23301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48377-4236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-395-7540
Provider Business Mailing Address Fax Number:
734-487-5173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
799 N HEWITT RD
Provider Second Line Business Practice Location Address:
142 CONVOCATION CENTER
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-487-5179
Provider Business Practice Location Address Fax Number:
734-487-5173
Provider Enumeration Date:
01/26/2007

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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