Provider Demographics
NPI:1720157308
Name:SASAKI, MASAHARU (DC,LAC)
Entity type:Individual
Prefix:
First Name:MASAHARU
Middle Name:
Last Name:SASAKI
Suffix:
Gender:M
Credentials:DC,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17502 IRVINE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3127
Mailing Address - Country:US
Mailing Address - Phone:714-665-1354
Mailing Address - Fax:
Practice Address - Street 1:17502 IRVINE BLVD
Practice Address - Street 2:STE A
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3127
Practice Address - Country:US
Practice Address - Phone:714-665-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0165110Medicare ID - Type Unspecified