Provider Demographics
NPI:1710497045
Name:OSATHANUGRAH, VIMOLROJ (LAC, OMD)
Entity Type:Individual
Prefix:
First Name:VIMOLROJ
Middle Name:
Last Name:OSATHANUGRAH
Suffix:
Gender:F
Credentials:LAC, OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 NANTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-1927
Mailing Address - Country:US
Mailing Address - Phone:213-344-7255
Mailing Address - Fax:
Practice Address - Street 1:2611 NANTUCKET AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-1927
Practice Address - Country:US
Practice Address - Phone:213-344-7255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12713171100000X
NV1052171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist