Provider Demographics
NPI:1518557016
Name:BASUKI, YUNITRISUWANTO
Entity Type:Individual
Prefix:MR
First Name:YUNITRISUWANTO
Middle Name:
Last Name:BASUKI
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 1:16011 S WESTERN AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3736
Mailing Address - Country:US
Mailing Address - Phone:310-866-2340
Mailing Address - Fax:
Practice Address - Street 1:625 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1409
Practice Address - Country:US
Practice Address - Phone:310-393-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8254225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist