Healthcare Provider Details

I. General information

NPI: 1144176082
Provider Name (Legal Business Name): KONGKRIT SRISUWAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15556 VANOWEN ST APT 5
VAN NUYS CA
91406-5145
US

IV. Provider business mailing address

15556 VANOWEN ST APT 5
VAN NUYS CA
91406-5145
US

V. Phone/Fax

Practice location:
  • Phone: 626-378-1428
  • Fax:
Mailing address:
  • Phone: 626-378-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number86835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: