MEDICARE: MR. PAUL KEONI NIIYAMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174H00000X	Health Educator

General Provider Information

NPI Number	:	1811211469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL KEONI NIIYAMA

Provider Business Mailing Address
First Line	:	14532 FRIAR ST STE G
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91411-2358
Country	:	US
Telephone Number	:	818-994-2108
Fax Number	:

Provider Business Practice Location Address
First Line	:	14532 FRIAR ST STE G
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91411-2358
Country	:	US
Telephone Number	:	818-994-2108
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2010
Last Update Date	:	03/24/2010

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