Provider Demographics
NPI:1386397974
Name:PATTHANADETTRAKUL, KASANU
Entity type:Individual
Prefix:
First Name:KASANU
Middle Name:
Last Name:PATTHANADETTRAKUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15511 SHERMAN WAY APT 43
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4156
Mailing Address - Country:US
Mailing Address - Phone:949-524-2555
Mailing Address - Fax:
Practice Address - Street 1:15511 SHERMAN WAY APT 43
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4156
Practice Address - Country:US
Practice Address - Phone:949-524-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA243225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10431980OtherLA CARE