Healthcare Provider Details

I. General information

NPI: 1740649482
Provider Name (Legal Business Name): ATH KITTIPHANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

1216 COLLIER AVE
MODESTO CA
95350-5302
US

V. Phone/Fax

Practice location:
  • Phone: 209-281-8467
  • Fax: 209-558-4873
Mailing address:
  • Phone: 209-499-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: