Provider Demographics
NPI:1245450592
Name:KOMIYAMA, KEIKO
Entity type:Individual
Prefix:MS
First Name:KEIKO
Middle Name:
Last Name:KOMIYAMA
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 1:12133 MITCHELL AVE APT 337
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4543
Mailing Address - Country:US
Mailing Address - Phone:310-497-0041
Mailing Address - Fax:
Practice Address - Street 1:815 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3340
Practice Address - Country:US
Practice Address - Phone:323-933-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10994171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist