Healthcare Provider Details

I. General information

NPI: 1588121362
Provider Name (Legal Business Name): MR. LAYNE SEICHI WAKUTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 W 162ND ST
GARDENA CA
90247-3734
US

IV. Provider business mailing address

1670 W. 162ND ST
GARDENA CA
90247
US

V. Phone/Fax

Practice location:
  • Phone: 310-483-8198
  • Fax:
Mailing address:
  • Phone: 310-217-9537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: