Healthcare Provider Details

I. General information

NPI: 1124847892
Provider Name (Legal Business Name): PRAPHAIPHAN(MARIA) WONGSUWAN-XENOPHONTOS MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIA WONGSUWAN MASSAGE THERAPIST

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 04/12/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 SPRUCE ST STE E
RIVERSIDE CA
92507-2352
US

IV. Provider business mailing address

1303 E CENTRAL AVE UNIT B
REDLANDS CA
92374-4010
US

V. Phone/Fax

Practice location:
  • Phone: 627-421-8875
  • Fax:
Mailing address:
  • Phone: 626-421-8875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number66452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: