Provider Demographics
NPI:1699947762
Name:ICHIHASHI, KOJI (LAC)
Entity type:Individual
Prefix:MR
First Name:KOJI
Middle Name:
Last Name:ICHIHASHI
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 1:30 VIA HOLON APT 5
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1913
Mailing Address - Country:US
Mailing Address - Phone:415-497-0751
Mailing Address - Fax:
Practice Address - Street 1:845 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4807
Practice Address - Country:US
Practice Address - Phone:415-497-0751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 1357171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist