Healthcare Provider Details

I. General information

NPI: 1336332139
Provider Name (Legal Business Name): SCOTT MIZUFUKA MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N LAKEVIEW AVE
ANAHEIM CA
92807-3028
US

IV. Provider business mailing address

441 N LAKEVIEW AVENUE
ANAHEIM CA
92807
US

V. Phone/Fax

Practice location:
  • Phone: 888-232-3030
  • Fax:
Mailing address:
  • Phone: 714-915-4612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 28192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: