Healthcare Provider Details

I. General information

NPI: 1720165301
Provider Name (Legal Business Name): ROY KENJI TAKEMURA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21018 GOLDEN SPRINGS DR
WALNUT CA
91789-3831
US

IV. Provider business mailing address

21018 GOLDEN SPRINGS DR
WALNUT CA
91789-3831
US

V. Phone/Fax

Practice location:
  • Phone: 909-594-3600
  • Fax: 909-594-4264
Mailing address:
  • Phone: 909-594-3600
  • Fax: 909-594-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5784T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: