Provider Demographics
NPI:1144828633
Name:YASUMARU, KIKUYO
Entity type:Individual
Prefix:
First Name:KIKUYO
Middle Name:
Last Name:YASUMARU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 N PARK WESTERN DR APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2321
Mailing Address - Country:US
Mailing Address - Phone:424-212-2483
Mailing Address - Fax:
Practice Address - Street 1:1218 N PARK WESTERN DR APT 3
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2321
Practice Address - Country:US
Practice Address - Phone:424-212-2483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
57242225700000X
CA57242225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist