Healthcare Provider Details

I. General information

NPI: 1306351069
Provider Name (Legal Business Name): ISSEI MIYAGUCHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 MOIX BLVD APT 615
CONWAY AR
72034-6975
US

IV. Provider business mailing address

2201 MOIX BLVD APT. 615
CONWAY AR
72034
US

V. Phone/Fax

Practice location:
  • Phone: 501-269-9614
  • Fax:
Mailing address:
  • Phone: 501-269-9614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: