Healthcare Provider Details

I. General information

NPI: 1164143301
Provider Name (Legal Business Name): JUN MIZUTANI PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12641 LONGLEAF DR
LA MIRADA CA
90638-2019
US

IV. Provider business mailing address

12641 LONGLEAF DR
LA MIRADA CA
90638-2019
US

V. Phone/Fax

Practice location:
  • Phone: 424-202-1951
  • Fax:
Mailing address:
  • Phone: 424-202-1951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number41773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: