Provider Demographics
NPI:1568276954
Name:IDA, KEISUKE (ATC, MT)
Entity type:Individual
Prefix:MR
First Name:KEISUKE
Middle Name:
Last Name:IDA
Suffix:
Gender:M
Credentials:ATC, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 PADSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8806
Mailing Address - Country:US
Mailing Address - Phone:916-865-7990
Mailing Address - Fax:
Practice Address - Street 1:2040 PADSIDE DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-8806
Practice Address - Country:US
Practice Address - Phone:916-865-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist