Provider Demographics
NPI:1053960286
Name:HATANAKA, KYLE HIROMI (LAC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:HIROMI
Last Name:HATANAKA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:HIROMI
Other - Last Name:HATANAKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5112 NE 47TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2066
Mailing Address - Country:US
Mailing Address - Phone:530-515-1064
Mailing Address - Fax:
Practice Address - Street 1:9450 #120 FAIRVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:530-515-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist