Healthcare Provider Details

I. General information

NPI: 1649840661
Provider Name (Legal Business Name): DEREK TAISHI NORIMOTO PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 N SANTA ANITA AVE
ARCADIA CA
91006-3114
US

IV. Provider business mailing address

12353 EVENSONG DR
LOS ANGELES CA
90064-3531
US

V. Phone/Fax

Practice location:
  • Phone: 626-294-0070
  • Fax:
Mailing address:
  • Phone: 310-892-9248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number300217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: