Provider Demographics
NPI:1871877837
Name:IMAZUMI-TANG, KEIKO MARIANNE (PT, MSPT, DPT)
Entity type:Individual
Prefix:
First Name:KEIKO
Middle Name:MARIANNE
Last Name:IMAZUMI-TANG
Suffix:
Gender:F
Credentials:PT, MSPT, DPT
Other - Prefix:
Other - First Name:KEIKO
Other - Middle Name:MARIANNE
Other - Last Name:IMAZUMI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, MSPT, DPT
Mailing Address - Street 1:5266 WAR WAGON CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-3359
Mailing Address - Country:US
Mailing Address - Phone:408-605-9300
Mailing Address - Fax:
Practice Address - Street 1:270 INTERNATIONAL CIR
Practice Address - Street 2:BUILDING 2 NORTH
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1130
Practice Address - Country:US
Practice Address - Phone:408-972-3528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38245225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist