Provider Demographics
NPI:1528070364
Name:ITO, KERRY A (DC)
Entity type:Individual
Prefix:MS
First Name:KERRY
Middle Name:A
Last Name:ITO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:1746 GRAND CANAL BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8111
Mailing Address - Country:US
Mailing Address - Phone:209-473-3308
Mailing Address - Fax:209-473-7855
Practice Address - Street 1:1746 GRAND CANAL BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8111
Practice Address - Country:US
Practice Address - Phone:209-473-3308
Practice Address - Fax:209-473-7855
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA21723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0217230Medicare ID - Type Unspecified