=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376180786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAKUMI FUKUNAGA DPT, SCS, ATC, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2019
-----------------------------------------------------
Last Update Date | 12/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 E 64TH ST FL 5
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-7471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-434-2700
-----------------------------------------------------
Fax | 212-434-2687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 E 64TH ST FL 5
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-7471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-434-2700
-----------------------------------------------------
Fax | 212-434-2687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 001601
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 030926
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------