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General NPI Number Information
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NPI Number | 1780132274
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Entity Type | Individual
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Provider Name | TETSUYA ENOMOTO
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Gender | Male
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Dates
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Enumeration Date | 09/14/2016
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Last Update Date | 09/14/2016
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Provider Practice Location Address
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Address Line | 11037 SAN JUAN ST
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City | LOMA LINDA
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State | CA
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Zip | 92354-2713
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Country | US
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Telephone | 951-907-7748
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Fax |
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Provider Business Mailing Address
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Address Line | 11037 SAN JUAN ST
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City | LOMA LINDA
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State | CA
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Zip | 92354-2713
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Country | US
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Telephone | 951-907-7748
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 10269
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License Number State | CA
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