Healthcare Provider Details

I. General information

NPI: 1942625066
Provider Name (Legal Business Name): YUYA MUKAIHARA ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 E RAAB RD
NORMAL IL
61761-9487
US

IV. Provider business mailing address

403 GREENBRIAR DR APT 214
NORMAL IL
61761-6221
US

V. Phone/Fax

Practice location:
  • Phone: 541-602-9050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003468
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: