Provider Demographics
NPI:1225814254
Name:SABPRASONG, VISUWATH GOLF (PTA)
Entity Type:Individual
Prefix:
First Name:VISUWATH
Middle Name:GOLF
Last Name:SABPRASONG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 W 17TH ST APT J37
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2305
Mailing Address - Country:US
Mailing Address - Phone:714-702-4105
Mailing Address - Fax:
Practice Address - Street 1:24050 ALISO CREEK RD STE 1C
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3937
Practice Address - Country:US
Practice Address - Phone:949-317-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52725225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant