| Street | 3 Chome-1-5 Izumitamatsuyu | ||
| City/Town | いわき市 | ||
| State/Province/Region | 福島県 | ||
| Zip/Postal Code | 971-8172 | ||
| Phone Number | 0246-56-2289 | ||
| Country | Japan |
| Full Name | 山岸 陽一 | ||
| Gender | male | ||
| Birthday | 1973-10-04 | ||
| Social Security Number |
| Credit card brand | Diners Club | ||
| Credit card number | 3018645096311804 | ||
| Expire | 2029/2 | ||
| CVV | 520 |