Provider Demographics
NPI:1154031797
Name:KIKUMOTO, LINDSEY
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:KIKUMOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S FREMONT AVE, UNIT 7, BLDG A10, STE. N10100
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803
Mailing Address - Country:US
Mailing Address - Phone:626-457-4240
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE, UNIT 7, BLDG A10, STE. N10100
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803
Practice Address - Country:US
Practice Address - Phone:626-457-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant