Provider Demographics
NPI:1467138461
Name:CHANCHAIVIT, RAIWAT
Entity Type:Individual
Prefix:
First Name:RAIWAT
Middle Name:
Last Name:CHANCHAIVIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 BREN MAR DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-6342
Mailing Address - Country:US
Mailing Address - Phone:703-477-8988
Mailing Address - Fax:
Practice Address - Street 1:6303 BREN MAR DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-6342
Practice Address - Country:US
Practice Address - Phone:703-477-8988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011228225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist