Healthcare Provider Details

I. General information

NPI: 1023938685
Provider Name (Legal Business Name): NICOLAS TAKEYOSHI KIYOHARA PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13931 CARROLL WAY STE B
TUSTIN CA
92780-1861
US

IV. Provider business mailing address

3230 E IMPERIAL HWY STE 100
BREA CA
92821-6735
US

V. Phone/Fax

Practice location:
  • Phone: 714-988-8120
  • Fax: 714-988-8119
Mailing address:
  • Phone: 714-988-8110
  • Fax: 714-988-8111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: