Healthcare Provider Details

I. General information

NPI: 1679771638
Provider Name (Legal Business Name): KENNETH SHINJI KISHIHARA O.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 N WHITNEY AVE SUITE 102
FRESNO CA
93720-0153
US

IV. Provider business mailing address

47900 WILLOW POND RD
COARSEGOLD CA
93614-8720
US

V. Phone/Fax

Practice location:
  • Phone: 559-323-4831
  • Fax: 559-323-4815
Mailing address:
  • Phone: 559-683-5460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT3030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: