Healthcare Provider Details

I. General information

NPI: 1952065740
Provider Name (Legal Business Name): RAIKI MIYAZATO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 N BELLFLOWER BLVD
LONG BEACH CA
90840-0004
US

IV. Provider business mailing address

392 W SUMMERFIELD CIR
ANAHEIM CA
92802-4775
US

V. Phone/Fax

Practice location:
  • Phone: 714-785-6073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: