=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336135888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLIFFORD A FUKUSHIMA OD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2005
-----------------------------------------------------
Last Update Date | 09/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 W HILLSDALE AVE STE D
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93291-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-625-5464
-----------------------------------------------------
Fax | 559-625-0714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 W HILLSDALE AVE STE D
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93291-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-625-5464
-----------------------------------------------------
Fax | 559-625-0714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CLIFFORD AIKO FUKUSHIMA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 559-625-5464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT6441T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------