Healthcare Provider Details

I. General information

NPI: 1225664626
Provider Name (Legal Business Name): KACEY CHIHO MIYAGISHIMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 IMPERIAL HWY
DOWNEY CA
90242-3456
US

IV. Provider business mailing address

22372 DESTELLO
MISSION VIEJO CA
92691-1528
US

V. Phone/Fax

Practice location:
  • Phone: 562-385-7111
  • Fax:
Mailing address:
  • Phone: 949-463-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number31389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: