Provider Demographics
NPI:1063015360
Name:CHAIBANG, TIPPAWON
Entity type:Individual
Prefix:
First Name:TIPPAWON
Middle Name:
Last Name:CHAIBANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7937 VANTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-2411
Mailing Address - Country:US
Mailing Address - Phone:818-423-6982
Mailing Address - Fax:
Practice Address - Street 1:7937 VANTAGE AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-2411
Practice Address - Country:US
Practice Address - Phone:818-423-6982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75623225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist