Healthcare Provider Details

I. General information

NPI: 1063323095
Provider Name (Legal Business Name): SAKURA TANAKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 OLIVE AVE
LONG BEACH CA
90802-1546
US

IV. Provider business mailing address

11002 AUGUSTA WAY
STANTON CA
90680-2809
US

V. Phone/Fax

Practice location:
  • Phone: 562-435-4496
  • Fax:
Mailing address:
  • Phone: 657-257-8075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: