Basic Information
Provider Information
NPI: 1003004342
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TANAKA
FirstName: SHINGO
MiddleName:  
NamePrefix: MR.
NameSuffix:  
Credential: MPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 225 EAGLE CREST ST
Address2:  
City: RANGELY
State: CO
PostalCode: 816483105
CountryCode: US
TelephoneNumber: 9706754205
FaxNumber: 9706754270
Practice Location
Address1: 225 EAGLE CREST ST
Address2:  
City: RANGELY
State: CO
PostalCode: 816483105
CountryCode: US
TelephoneNumber: 9706754205
FaxNumber: 9706754270
Other Information
ProviderEnumerationDate: 10/11/2007
LastUpdateDate: 10/10/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X10367COY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000XPT011869OHN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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