Healthcare Provider Details

I. General information

NPI: 1386047751
Provider Name (Legal Business Name): SYLAS TAKAMUNE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 W POWELL BLVD
GRESHAM OR
97030-6413
US

IV. Provider business mailing address

2519 W POWELL BLVD
GRESHAM OR
97030-6413
US

V. Phone/Fax

Practice location:
  • Phone: 971-258-4607
  • Fax:
Mailing address:
  • Phone: 971-258-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5588
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: