Healthcare Provider Details

I. General information

NPI: 1205346012
Provider Name (Legal Business Name): YUKI OKAMOTO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 MESA COLLEGE DR
SAN DIEGO CA
92111-4902
US

IV. Provider business mailing address

4847 W MOUNTAIN VIEW DR APT 6
SAN DIEGO CA
92116-1746
US

V. Phone/Fax

Practice location:
  • Phone: 619-980-9057
  • Fax: 619-980-9057
Mailing address:
  • Phone: 619-980-9057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000030291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: