Healthcare Provider Details

I. General information

NPI: 1720168677
Provider Name (Legal Business Name): DIANE SHIRAISHI & CHRIS OTA PTRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 E HAMILTON AVE
CAMPBELL CA
95008-0234
US

IV. Provider business mailing address

163 E HAMILTON AVE
CAMPBELL CA
95008-0234
US

V. Phone/Fax

Practice location:
  • Phone: 408-866-5567
  • Fax: 408-866-1317
Mailing address:
  • Phone: 408-866-5567
  • Fax: 408-866-1317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT132250
License Number StateCA

VIII. Authorized Official

Name: MR. CHRIS M. OTA
Title or Position: OWNER
Credential: PT
Phone: 408-866-5567