Provider Demographics
NPI:1487805974
Name:MIURA, KYLE MASAMI (DAOM MPH, MSOM, MDIV)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MASAMI
Last Name:MIURA
Suffix:
Gender:M
Credentials:DAOM MPH, MSOM, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 SAN PABLO AVE APT 213
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1159
Mailing Address - Country:US
Mailing Address - Phone:510-289-1266
Mailing Address - Fax:
Practice Address - Street 1:1760 SOLANO AVE STE 201
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2218
Practice Address - Country:US
Practice Address - Phone:510-289-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12535171100000X
HI862171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist