Provider Demographics
NPI:1003952748
Name:LAMYAITHONG, ALELI RAMISCAL (RPT)
Entity Type:Individual
Prefix:MRS
First Name:ALELI
Middle Name:RAMISCAL
Last Name:LAMYAITHONG
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-1115
Mailing Address - Country:US
Mailing Address - Phone:304-583-2608
Mailing Address - Fax:
Practice Address - Street 1:125C MAIN ST
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1211
Practice Address - Country:US
Practice Address - Phone:304-583-8808
Practice Address - Fax:304-583-8809
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302248-000Medicaid
WV001711895OtherBCBS