Healthcare Provider Details

I. General information

NPI: 1205837986
Provider Name (Legal Business Name): TED H. OMURA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 MERIDIAN AVE
SAN JOSE CA
95125-5532
US

IV. Provider business mailing address

1609 MERIDIAN AVE
SAN JOSE CA
95125-5532
US

V. Phone/Fax

Practice location:
  • Phone: 408-448-8818
  • Fax:
Mailing address:
  • Phone: 408-448-8818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC025988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: