Provider Demographics
NPI:1417695412
Name:PHOPHUTTHAPRASIT, GRITCHALACH (AP, DOM)
Entity Type:Individual
Prefix:MR
First Name:GRITCHALACH
Middle Name:
Last Name:PHOPHUTTHAPRASIT
Suffix:
Gender:M
Credentials:AP, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2501 S VOLUSIA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9134
Mailing Address - Country:US
Mailing Address - Phone:386-774-3333
Mailing Address - Fax:386-410-1603
Practice Address - Street 1:3739 LAKE CENTER DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2363
Practice Address - Country:US
Practice Address - Phone:352-729-2290
Practice Address - Fax:386-774-6333
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4357171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist