Healthcare Provider Details

I. General information

NPI: 1003004342
Provider Name (Legal Business Name): SHINGO TANAKA MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 EAGLE CREST ST
RANGELY CO
81648-3105
US

IV. Provider business mailing address

225 EAGLE CREST ST
RANGELY CO
81648-3105
US

V. Phone/Fax

Practice location:
  • Phone: 970-675-4205
  • Fax: 970-675-4270
Mailing address:
  • Phone: 970-675-4205
  • Fax: 970-675-4270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011869
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10367
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: