=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104768563
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOKIAT WONGPIRIYAKUN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2026
-----------------------------------------------------
Last Update Date | 04/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4030 BIRCH ST STE 102
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-932-0624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3284 SAN AMADEO UNIT A
-----------------------------------------------------
City | LAGUNA WOODS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92637-8408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-290-7741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 100362
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------