Healthcare Provider Details

I. General information

NPI: 1194473710
Provider Name (Legal Business Name): KRITTUSSAPON KHEAWBUA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14030 CHADRON AVE APT 235
HAWTHORNE CA
90250-8247
US

IV. Provider business mailing address

14030 CHADRON AVE APT 235
HAWTHORNE CA
90250-8247
US

V. Phone/Fax

Practice location:
  • Phone: 310-456-4999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number85742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: