Provider Demographics
NPI:1487329058
Name:MONGKOLLA, NUNTHICHA
Entity type:Individual
Prefix:
First Name:NUNTHICHA
Middle Name:
Last Name:MONGKOLLA
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 1:3200 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-3014
Mailing Address - Country:US
Mailing Address - Phone:213-559-7131
Mailing Address - Fax:
Practice Address - Street 1:11740 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6610
Practice Address - Country:US
Practice Address - Phone:310-442-1901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86844225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86844OtherMASSAGE THERAPIST CERTIFICATION