Healthcare Provider Details

I. General information

NPI: 1275527301
Provider Name (Legal Business Name): MITSUMARO MOTOYOSHI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 OAKDALE ST SUITE B
FOLSOM CA
95630-2451
US

IV. Provider business mailing address

555 OAKDALE ST
FOLSOM CA
95630-2451
US

V. Phone/Fax

Practice location:
  • Phone: 916-353-0197
  • Fax: 916-608-4956
Mailing address:
  • Phone: 916-353-0197
  • Fax: 916-608-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: