Provider Demographics
NPI:1124630306
Name:TANGSOPON, BOONSITA
Entity type:Individual
Prefix:
First Name:BOONSITA
Middle Name:
Last Name:TANGSOPON
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 1:12444 VICTORY BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3156
Mailing Address - Country:US
Mailing Address - Phone:747-203-4951
Mailing Address - Fax:
Practice Address - Street 1:12444 VICTORY BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3156
Practice Address - Country:US
Practice Address - Phone:747-203-4951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16221171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist