Provider Demographics
NPI:1104876275
Name:ITO, BRIAN TAKESHI (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:TAKESHI
Last Name:ITO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5277 MEADOWRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-4128
Mailing Address - Country:US
Mailing Address - Phone:805-383-1650
Mailing Address - Fax:
Practice Address - Street 1:4247 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3705
Practice Address - Country:US
Practice Address - Phone:805-644-5563
Practice Address - Fax:805-644-3430
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30009111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC30009Medicare PIN