Healthcare Provider Details

I. General information

NPI: 1073636478
Provider Name (Legal Business Name): JANE M. MITSUMORI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9122 ADAMS AVE
HUNTINGTON BEACH CA
92646-3405
US

IV. Provider business mailing address

9122 ADAMS AVE
HUNTINGTON BEACH CA
92646-3405
US

V. Phone/Fax

Practice location:
  • Phone: 714-962-1780
  • Fax: 714-378-5166
Mailing address:
  • Phone: 714-962-1780
  • Fax: 714-378-5166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT10043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: