Healthcare Provider Details

I. General information

NPI: 1194478818
Provider Name (Legal Business Name): MS. MARI TOMIKO FUKUSHIMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 RIO LINDO AVE
CHICO CA
95926-1817
US

IV. Provider business mailing address

592 RIO LINDO AVE
CHICO CA
95926-1817
US

V. Phone/Fax

Practice location:
  • Phone: 530-891-2775
  • Fax:
Mailing address:
  • Phone: 530-891-2775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number49793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: