Provider Demographics
NPI:1003299157
Name:TRATENG, KAMOLLUCK (LAC)
Entity Type:Individual
Prefix:
First Name:KAMOLLUCK
Middle Name:
Last Name:TRATENG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 POLLARD RD STE B203
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1429
Mailing Address - Country:US
Mailing Address - Phone:408-409-5005
Mailing Address - Fax:
Practice Address - Street 1:800 POLLARD RD STE B203
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1429
Practice Address - Country:US
Practice Address - Phone:408-409-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 16450171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist