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General NPI Number Information
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NPI Number | 1598579930
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Entity Type | Individual
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Provider Name | JIRISUDA PISUTHIPRAKORN
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Gender | Female
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Dates
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Enumeration Date | 02/05/2025
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 13691 GAVINA AVE UNIT 567
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City | SYLMAR
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State | CA
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Zip | 91342-2670
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Country | US
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Telephone | 818-644-1995
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Fax | 818-591-8426
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Provider Business Mailing Address
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Address Line | 13691 GAVINA AVE UNIT 567
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City | SYLMAR
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State | CA
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Zip | 91342-2670
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Country | US
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Telephone | 818-644-1995
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Fax | 818-591-8426
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 84208
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License Number State | CA
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