Healthcare Provider Details

I. General information

NPI: 1023049673
Provider Name (Legal Business Name): EDWIN KAZUO KIKUCHI MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29099HOSPITAL ROAD SUITE 209
LAKE ARROWHEAD CA
92352
US

IV. Provider business mailing address

PO BOX 33
RUNNING SPRINGS CA
92382-0033
US

V. Phone/Fax

Practice location:
  • Phone: 909-337-8219
  • Fax: 909-337-8920
Mailing address:
  • Phone: 909-867-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS4695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: