Healthcare Provider Details

I. General information

NPI: 1528897295
Provider Name (Legal Business Name): LUCILE ISHIZUKA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 GARFIELD AVE
CARMICHAEL CA
95608-6647
US

IV. Provider business mailing address

32 MOSSGLEN CIR
SACRAMENTO CA
95826-1723
US

V. Phone/Fax

Practice location:
  • Phone: 916-481-6455
  • Fax:
Mailing address:
  • Phone: 916-796-5617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: