Healthcare Provider Details

I. General information

NPI: 1396231387
Provider Name (Legal Business Name): MOTOKI KAMIKURA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 EDGEMONT BLVD
ALAMOSA CO
81101-2320
US

IV. Provider business mailing address

208 EDGEMONT BLVD
ALAMOSA CO
81101-2320
US

V. Phone/Fax

Practice location:
  • Phone: 719-587-7011
  • Fax:
Mailing address:
  • Phone: 719-587-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT.0001619
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: