MEDICARE: MS. CHALISA THAVONRUNGKIT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	76682	CA

General Provider Information

NPI Number	:	1497353940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHALISA THAVONRUNGKIT

Provider Business Mailing Address
First Line	:	5440 CARLTON WAY APT 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-4878
Country	:	US
Telephone Number	:	213-268-1246
Fax Number	:

Provider Business Practice Location Address
First Line	:	5440 CARLTON WAY APT 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-4878
Country	:	US
Telephone Number	:	213-268-1246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2020
Last Update Date	:	10/15/2020

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