Healthcare Provider Details

I. General information

NPI: 1508599440
Provider Name (Legal Business Name): TYLER KOJIMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N ORCHARD ST
BOISE ID
83706-2231
US

IV. Provider business mailing address

1003 N ORCHARD ST
BOISE ID
83706-2231
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-3113
  • Fax:
Mailing address:
  • Phone: 208-376-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS-3915
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: