Healthcare Provider Details

I. General information

NPI: 1205108578
Provider Name (Legal Business Name): YUTTHANA TOKIJKLA ATP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1972 GINKGO ST
SAN BERNARDINO CA
92407-2365
US

IV. Provider business mailing address

1972 GINKGO ST
SAN BERNARDINO CA
92407-2365
US

V. Phone/Fax

Practice location:
  • Phone: 909-289-5874
  • Fax:
Mailing address:
  • Phone: 909-289-5874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225CA2500X
TaxonomyAssistive Technology Supplier Rehabilitation Counselor
License NumberATP4665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: