Healthcare Provider Details

I. General information

NPI: 1669750584
Provider Name (Legal Business Name): KENTO KAMIYAMA P.T., D.P.T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 BROADWAY CONCOURSE LANE 1
NEW YORK NY
10018
US

IV. Provider business mailing address

1 ORIENT WAY STE F217
RUTHERFORD NJ
07070
US

V. Phone/Fax

Practice location:
  • Phone: 201-655-9029
  • Fax: 201-327-1921
Mailing address:
  • Phone: 201-327-1990
  • Fax: 201-327-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01402100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0382441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: