Basic Information
| Provider Information | |||||||||
| NPI: | 1134179377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IKIGAI PHYSICIAN GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1523 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORTUNA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955402430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077262255 | ||||||||
| FaxNumber: | 7079499715 | ||||||||
| Practice Location | |||||||||
| Address1: | 3429 RENNER DR | ||||||||
| Address2: | |||||||||
| City: | FORTUNA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955403104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077262255 | ||||||||
| FaxNumber: | 7079499715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SISSON | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | JOAN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7077262255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16812 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0048520 | 05 | CA | MEDICAID | RHM053946F | 05 | CA | MEDICAID | RHM053945F | 05 | CA | MEDICAID |