Healthcare Provider Details

I. General information

NPI: 1790614162
Provider Name (Legal Business Name): MR. CHANACHON SRISAARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21500 LASSEN ST SPC 143
CHATSWORTH CA
91311-0832
US

IV. Provider business mailing address

21500 LASSEN ST SPC 143
CHATSWORTH CA
91311-0832
US

V. Phone/Fax

Practice location:
  • Phone: 818-614-8522
  • Fax:
Mailing address:
  • Phone: 818-614-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number83732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: