Healthcare Provider Details

I. General information

NPI: 1154483915
Provider Name (Legal Business Name): OMI IWASAKI PT, DPT, OCS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SANTA MONICA BLVD SUITE 401
SANTA MONICA CA
90404-2023
US

IV. Provider business mailing address

18400 AVALON BLVD SUITE 800
CARSON CA
90746-2172
US

V. Phone/Fax

Practice location:
  • Phone: 310-573-8866
  • Fax:
Mailing address:
  • Phone: 310-630-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number25044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: