Healthcare Provider Details

I. General information

NPI: 1073642252
Provider Name (Legal Business Name): TAKAYUKI KUWAHARA LIC. AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CHURCH ST
WATERTOWN MA
02472-3855
US

IV. Provider business mailing address

12 WESTMINSTER AVE
WATERTOWN MA
02472-3645
US

V. Phone/Fax

Practice location:
  • Phone: 617-926-6986
  • Fax:
Mailing address:
  • Phone: 617-926-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number397
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: