Healthcare Provider Details

I. General information

NPI: 1750565214
Provider Name (Legal Business Name): KESARIN BUMROONGNANGAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W TEMPLE ST FL 9
LOS ANGELES CA
90012-3217
US

IV. Provider business mailing address

320 W TEMPLE ST FL 9
LOS ANGELES CA
90012-3217
US

V. Phone/Fax

Practice location:
  • Phone: 213-974-7102
  • Fax: 213-620-1405
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: