Healthcare Provider Details

I. General information

NPI: 1487805974
Provider Name (Legal Business Name): KYLE MASAMI MIURA DAOM MPH, MSOM, MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 SOLANO AVE STE 201
BERKELEY CA
94707-2218
US

IV. Provider business mailing address

727 SAN PABLO AVE APT 213
ALBANY CA
94706-1159
US

V. Phone/Fax

Practice location:
  • Phone: 510-289-1266
  • Fax:
Mailing address:
  • Phone: 510-289-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number12535
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number862
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: