=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457895633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ITO PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2016
-----------------------------------------------------
Last Update Date | 12/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2863 SERANG PL
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-4826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-439-5344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2863 SERANG PL
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-4826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT292464
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------