Provider Demographics
NPI:1194122663
Name:MATSUDA, LUKE TOMOGIRO (LAC)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:TOMOGIRO
Last Name:MATSUDA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 E 100 N STE 2
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2711
Mailing Address - Country:US
Mailing Address - Phone:435-650-2302
Mailing Address - Fax:
Practice Address - Street 1:894 E 100 N STE 2
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2711
Practice Address - Country:US
Practice Address - Phone:435-650-2302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-29
Last Update Date:2014-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9146400-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist