Provider Demographics
NPI:1487205548
Name:SANDAENG, SOMLAK
Entity Type:Individual
Prefix:
First Name:SOMLAK
Middle Name:
Last Name:SANDAENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 ROUTE 37 E
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-5752
Mailing Address - Country:US
Mailing Address - Phone:732-270-8424
Mailing Address - Fax:
Practice Address - Street 1:1214 ROUTE 37 E
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-5752
Practice Address - Country:US
Practice Address - Phone:732-270-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT0122340225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ81-4580365OtherOPTOM