Basic Information
| Provider Information | |||||||||
| NPI: | 1710282421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAKEUCHI WANLASS | ||||||||
| FirstName: | ISAAC | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, DPT | ||||||||
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| OtherLastName: | WANLASS | ||||||||
| OtherFirstName: | ISAAC | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3244 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905052719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105398800 | ||||||||
| FaxNumber: | 3106985410 | ||||||||
| Practice Location | |||||||||
| Address1: | 15477 VENTURA BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914033006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105398800 | ||||||||
| FaxNumber: | 8189862146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2011 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 37269 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.